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GROUP 1Abstract ID: 1Outcomes of Above Knee Amputation in Spinal Cord Injury Veteran PatientsIntroduction:Above knee amputation (AKA) is the primary treatment for non-ambulatory patients with non-healing lower extremity wounds. Patients with significant paralysis after spinal cord injury (SCI) are a unique population to which this procedure is offered. However, no large studies have documented outcomes of AKA in this population. Our objectives were to assess the outcomes of SCI patients who underwent AKA. Methods:Data of all patients who underwent AKA at our institution between 2010 and 2015 were collected via chart review (n=110). Patients were grouped based on a history of SCI (n=18) or the lack thereof (n=92). The primary outcome was mortality, stratified into 30-day, 1-year, and 3-year mortality. Secondary outcomes included cardiac complications, cerebrovascular accidents (CVA), pneumonia, wound-healing complications, and the necessity of revision. Outcomes between the two groups were analyzed using chi-square analysis.Results:Demographic information was largely similar between the two groups. Non-SCI patients were older (mean age 71.5 vs. 64.44 years, p=0.005) and more likely to have a history of hypertension (89.13% vs. 61.11%, p=0.003), peripheral artery disease (93.48% vs. 77.78%, p=0.034), and coronary artery disease (66.3% vs. 27.78%, p=0.002). 30-day mortality (6.52% vs. 0%, p=0.265) and 1-year mortality (32.61% vs. 11.11%, p=0.066) were similar across both groups. 3-year mortality was significantly higher in the non-SCI group (66.3% vs. 27.78%, p=0.002). No patients in the SCI group suffered from any cardiac complication, CVA, or pneumonia. One patient in this group developed a post-operative hematoma; otherwise, no wound-healing complications were noted.Conclusions:Similar 30-day and 1-year mortality were seen in both groups. However, SCI patients saw a long-term mortality benefit at 3 years. The SCI group was less likely to experience peri-operative cardiac events and experienced excellent wound-healing rates. AKA remains a safe, durable procedure for treatment of lower extremity wounds in the SCI population.Abstract ID: 2Lipoma Excision: A Single-Institution Cost AnalysisBackground: Lipomas are benign soft-tissue neoplasms of adipocytes. If a patient experiences pain, movement limitations, or cosmetic concerns, lipomatous masses may be surgically removed. Since lipomas do not infiltrate neighboring structures, they tend to be excised relatively easily. The benign nature of these tumors raises questions regarding the necessity of surgical excision, particularly in the context of associated cost and resource utilization.Objective: This article presents a summative outline of the epidemiology, pathogenesis, and factors affecting the management of lipomas, as well as the estimated economic burden associated with their excision. The aim of this review and cost analysis is to facilitate treatment decisions for surgeons and other clinicians who frequently encounter lipomas in their clinical practices.Methods: We obtained our institution’s charges and Medicare reimbursement (allowable) for lipoma excision based on designated Current Procedural Terminology (CPT) codes. The volume of lipoma excisions based on size and location were also obtained. We then correlated charges/allowable with procedure volume over three years to determine an estimated annual hospital charge and Medicare reimbursement for lipoma excision at our institution.Results: The Medicare allowable was significantly less than the full hospital charge for each of the procedures that we assessed. In total, $89.5 million in hospital charges was billed to Medicare between the years 2017 and 2019. The reimbursed Medicare allowable for lipoma excisions at our institution was between $900,000 and $5.1 million over three years. Conclusions: Lipomas present unique challenges to the practicing surgeon. Their bothersome nature leads many patients to seek simple excision. The relatively straight-forward excision makes it an attractive opportunity for surgeons to improve patient quality of life with minimal potential morbidity. Based on our findings, it is critical that surgeons make an effort to consider the high cost and resource utilization that lipoma excision requires.Abstract ID: 3The Effectiveness of Traditional Acupuncture in Veterans Undergoing Total Hip and Knee Replacement SurgeryIntroduction: Total joint replacement is a common surgery in the United States. Due to the risk of opioid medications, non-pharmacological treatments have been considered for postoperative pain management. In this investigation, we aimed to determine whether traditional acupuncture is effective in reducing pain and opioid use following total hip and knee arthroplasties. Methods: Following the approval of the Institutional Review Board (IRB) of the John D. Dingell VA medical center, a total of seventy veterans were randomly assigned into two groups: Treatment group, receiving traditional acupuncture, and Control group, receiving simulated acupuncture. In Treatment group, we inserted 4 small acupuncture needles around the hip/knee region and removed them after subjects reporting the stimulus. In control group, the acupuncture needles were introduced and removed immediately without patients receiving the necessary stimulus. Outcomes of interest included 24-hour postoperative pain, measured by a visual analog scale (VAS), average morphine milliequivalent (MME) use, and patient satisfaction on a scale from 1 to 10.Results: The study comprised 30 patients in Treatment group and 40 patients in Control group. All patients underwent total joint replacement under neuraxial anesthesia. Treatment group had lower average MME compared to Control group (19.55 vs 58.4, p<0.001). Average VAS score was lower in Treatment group at 6 hours (4 vs 6, p<0.001), 12 hours (3 vs 6, p<0.001), 18 hours (3 vs 4, p<0.001) and 24 hours (2 vs 4, p<0.001). Furthermore, Treatment group had higher patient satisfaction for pain management compared to Control group (8 vs 5, p<0.001).Conclusion:?This clinical trial demonstrated the effectiveness of traditional acupuncture in reducing 24-hour postoperative pain and opioid dependence in veterans undergoing total knee and hip replacement surgery.Abstract ID: 4Comparison Between General and Regional Anesthesia for Outcomes Following Primary Total Hip Arthroplasty in Veteran Health AdministrationIntroduction: Total hip replacement is a common orthopedic surgery. The aim of our study was to investigate the differences between general anesthesia and regional anesthesia for 30-day outcomes after primary total hip arthroplasty (PTHA) in United States veteran patients. To our knowledge, this is the first account from the Veterans Affairs hospitals for patients undergoing PTHA under different anesthetic modalities.Methods: We retrospectively reviewed the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database for patients who underwent PTHA from 2008 to 2015. Subjects were divided into two groups: general anesthesia (n=19,890) and regional anesthesia (n=4,250). The latter group included cases of spinal anesthesia, epidural anesthesia and regional nerve block, and comprised 17.6% of all cases. We utilized propensity score matching to adjust for patient baseline characteristics, and multivariate logistic regression to evaluate independent associations between anesthetic type and 30-day outcomes.Results: After propensity score matching, the two groups comprised 11,541 patients who were included in the data analysis. Average age of patients was 63 years, and most patients were males (95.7%). Multivariable analysis showed lower likelihood of postoperative unplanned reintubation in patients receiving regional anesthesia compared to general anesthesia (Adjusted Odds Ratio (AOR)= 0.4; 95% CI 0.18-0.92; p=0.018). Compared to general anesthesia, regional anesthesia was associated with higher odds of superficial surgical site infection (AOR=1.7; 95% CI 1.06-2.73; p=0.031), but the two groups were not different in overall wound infection occurence (AOR=1.08, 95% CI 0.77-1.51; p=0.67). The two anesthetic methods were not significantly different in rates of overall respiratory, cardiovascular and renal complciations, and in length of postoperative hospitatliztion. Conclusion: Compared to previous reports of national databases which estimated the frequency of regional anestehsia in PTHA is about 40%, regional anesthesia is underutilized in Veterans Affairs hospitals. Regional anesthesia is correlated with lower risk of postoperative reintubation, and higher risk of superficial wound infection. The two anesthetic methods were comparable in other postoperative outcomes.Abstract ID: 5Reduction in Chronic Opioid Use After Joint Surgery among Veterans Utilizing Multidisciplinary Approach to Perioperative Pain ManagementIntroduction: Chronic post-surgical pain and opioid use is a growing problem. To address these risks, a multidisciplinary approach to perioperative pain management known as the Transitional Pain Service (TPS) was developed at the Salt Lake City VA Medical Center (SLC-VAMC) consisting of coordinated pain management, education, care-coordination, and cognitive-behavioral therapy for at-risk veterans spanning pre-operatively to 6-months after surgery. This study was designed to evaluate the effectiveness of the TPS model among veterans undergoing orthopedic joint procedures.Methods: We conducted a pre-post study of all patients undergoing elective primary or revision total knee, hip, or shoulder replacement or rotator cuff repair procedures during the year before (2017) and after (2018) implementation of TPS at the SLC-VAMC. Opioid use among patients enrolled in TPS was compared to matched control patients from the year prior, and logistic regression models were used to assess the risk-adjusted association between TPS and chronic opioid use.Results: A total of 164 TPS patients that met inclusion criteria were matched with 172 control patients undergoing the same procedures who received standard care before the intervention was introduced. There was no significant difference in patient demographics or comorbidities between TPS and control cohorts. At 90 days after surgery, TPS was associated with a 68% lower likelihood of any opioid use [OR: 0.32 (95%CI:0.14-0.69); P<0.01) as compared to controls. Further, opioid na?ve patients enrolled in TPS were significantly less likely to develop new chronic opioid use after surgery (0.7% vs 8.4% p=0.004).Conclusions: These data suggest that the TPS is an effective strategy for preventing new chronic opioid use and reducing overall opioid use among Veterans undergoing major surgery. Future work is needed to evaluate the TPS among patients undergoing other surgical specialty procedures and to determine if this model can be reproduced in other VA health care systems.Abstract ID: 6Routine Histopathology of Gastric Sleeve Specimens Can Be Safely EliminatedRoutine Histopathology of Gastric Sleeve Specimens Can Be Safely Eliminated.Introduction: The sleeve gastrectomy (SG) is the most commonly performed bariatric operation and the resected stomach is routinely sent to pathology for gross and microscopic evaluation. The percentage of specimens with significant abnormalities is low and can usually be detected by gross examination and therefore routine microscopic analysis may not justify the cost. Methods: This is a retrospective review of a prospectively maintained database. IRB approval was obtained. All SGs performed from October 2010 to November 2019 were evaluated. Currently all specimens are submitted for gross and histopathologic examination along with determination of Helicobacter pylori status. Pathology reports were reviewed for abnormal gross or microscopic findings. A Fisher exact test was performed to determine if there was any relationship between abnormal pathology and major postoperative complications.Results: There were 301 SG specimens. The average patient age was 50.7 (25-68) years and the average BMI was 42.7 (33-65). There were 216 males and 85 females. Five (1.7%) gastrointestinal stromal tumors were identified and all were grossly detectable at the time of resection. There were no incidentally found adenocarcinomas or other malignancies. The majority of the pathology reports were normal (47.9%). Other findings included: chronic gastritis/inflammation (43.1%), H. pylori (8.0%), benign lymphoid aggregates (2.8%), fundic gland polyp (2.8%), mild surface degeneration (2.1%), active gastritis (1.4%), focal congestion (1.4%), focal intestinal metaplasia (1%), congested lamina propria (0.4%), and mucosa hyperplasia (0.4%). Two-tailed Fisher exact test found no statistically significant association between major post-operative complications and pathology results.Conclusions: Gross examination of SG specimens should always be performed. However, microscopic histopathology can be safely eliminated unless indicated by abnormal gross pathology. This approach would result in significant health care savings and not impact complication rates or postoperative care of the bariatric patient.Abstract ID: 7Comparing the Cost-Effectiveness of Fibrinolysis versus VATS Decortication for Early EmpyemaIntroduction: Surgical decortication is the guideline recommendation for management of early empyema, but intrapleural fibrinolysis is frequently used as first-line therapy. This study compared the cost effectiveness of video-assisted thoracoscopic surgery (VATS) decortication with intrapleural fibrinolysis for early empyema.Methods: A decision analysis model was developed. The base clinical case was a 65-year-old male with early empyema treated either by VATS decortication or intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNAse). The likelihood of key outcomes occurring was derived from the literature. Medicare diagnosis-related groups and manufacturers’ drug prices were used for cost estimates. Successful treatment was defined as complete or near-complete resolution of empyema on imaging. Effectiveness was defined as health utility one-year post-empyema. Results: Intrapleural tPA/DNAse was more cost-effective than VATS decortication for treating early empyema for the base scenario. VATS decortication had a slightly lower cost than fibrinolysis ($13,345 vs $13,965), but fibrinolysis had a marginally higher effectiveness at one year (health utility of 0.80 vs. 0.71) resulting in tPA/DNAse being the more cost-effective option. Sensitivity analyses found that fibrinolysis as the initial therapy was more cost-effective when the probability of success for tPA/DNAse was greater than 60% or the initial cost of fibrinolysis was less than $13,000.Conclusions: VATS decortication intrapleural tPA/DNAse have nearly equivalent cost-effectiveness for early empyema in patients that can tolerate both procedures. Surgeons should consider patient-specific factors as well as the cost and effectiveness of both modalities when deciding the initial treatment for early empyema.Abstract ID: 8Crisis of Confidence in Cardiothoracic Trainees: Examining National Trends in Use of Minimally Invasive EsophagectomyIntroduction: Esophagectomy is a highly morbid operation. A minimally invasive approach offers patients fewer complications without compromising oncologic outcomes. However, survey of recent cardiothoracic graduates suggests a crisis of confidence in performing minimally invasive esophagectomy, in part related to poor exposure during training. We sought to examine national trends in the use of minimally invasive esophagectomy. Methods: We conducted a retrospective analysis using medicare data of esophagectomies performed in the United States between 2016 and 2018. Data were organized by operative approach (open versus minimally invasive, and transhiatal versus Ivor Lewis). Descriptive statistics were used to assess the operative technique based on hospital factors including geographic region, facility size, and classification as a teaching versus private institution. Results: We examined 26,455 esophagectomies performed during the study period. Of these, 13,667 (51%) were transhiatal. Overall, 58% and 63% of transhiatal and Ivor Lewis esophagectomies, respectively, were performed minimally invasively. Use of minimally invasive surgery increased over time; however, use was more common at non-teaching hospitals. In 2016, 1,246 (58%) minimally invasive transhiatal procedures were performed at non-teaching hospitals as compared to 50% at teaching hospitals. This finding persisted over time, whereby a minimally invasive approach represented 69% as opposed to 59% of transhiatals performed at non-teaching as compared to teaching hospitals in 2018. A similar trend was found for Ivor Lewis esophagectomy. Operative technique varied geographically with use of minimally invasive Ivor Lewis being most common in the northeast (69%) as opposed to the western United States (59%). Conclusions: Our data suggest that while minimally invasive esophagectomy is becoming more pervasive, use varies geographically and is less common at teaching hospitals. This has important implications for cardiothoracic trainees who cite operative exposure as a major factor contributing to the likelihood of using this technique in practice.Abstract ID: 9Malignant hyperthermia, risk factors, and associated comorbidities: a literature reviewBackground:Malignant hyperthermia (MH) is a serious complication associated with a depolarizing neuromuscular junction blocker, succinylcholine, and volatile anesthetics. Its clinical symptoms include hyperthermia, hypercapnia, hyperkalemia and hypoxia. If not identified and treated immediately, it can lead to rhabdomyolysis, nephropathy, coma or death. Thus, it is imperative to identify individuals who are at increased risk. We aim to identify the epidemiological parameters of MH and to assess associations of MH with age, gender, ethnicity, geographical location and comorbid conditions. Methods:A literature review using the PubMed database was carried out combining search terms: malignant hyperthermia or malignant hyperthermia susceptibility and related diseases or comorbidities or comorbidity or chronic diseases or risk factors. Articles were also identified by manual search of bibliographies from all retrieved articles. Results:Nine retrospective chart review studies were analyzed. Overall, the reported incidence of MH varies between 1:30,000-250,000. Populations disproportionately affected were Caucasian males and children ( < 1 5 years). While Caucasians experienced a higher mortality compared to other races, positive family history was the strongest predictor for an episode. Mortality rates ranged from 11% to 64%, however has decreased significantly with the advent of Dantrolene and increasingly comprehensive pre-anesthesia screening assessments. Musculoskeletal and connective tissue disorders are most commonly associated with MH. Little research exists pertaining to the association between malignant hyperthermia and non-musculoskeletal disorders including cardiovascular and metabolic diseases.Conclusion:Sufficient literature exists pertaining to the epidemiology, pathogenesis, clinical sequelae and treatment of malignant hyperthermia. However, limited literature is available which examines associated comorbidities, including predisposing risk factors/conditions, and long-term outcomes. Future studies are warranted to assess whether specific comorbidities are associated with heightened risk of MH. This will help identify appropriate populations for which further pre-anesthesia work-up is warranted.Abstract ID: 10Outcomes of Hartmann’s Reversal in VeteransIntroduction: Hartmann’s reversal (HR) is perceived as a challenging procedure with reported mortality of 6-8% and morbidity up to 40%. This study examines the outcome of HR in Veterans. Methods: Veterans Affairs Surgical Quality Improvement Program data was utilized to select patients who underwent HR from 2008 to 2015.Univariate analysis was used to compare demographics, operative details, and postoperative outcomes in open (OHR) and laparoscopic (LHR) subgroups. A p value of ≤0.05 was considered significant. Results: A total of 1,417 patients were included (95% male,31% ≥65 years,32% with BMI≥30, and 79% ASA class III/IV). Complications occurred in 25.9% of cases, the most common being superficial surgical site infection (9.7%), reoperation (6.9%), organ space infection (4.2%),and wound dehiscence (3.8%). Overall length of stay(LOS) was 9.1±10.3 days, and 30-day mortality was 1% (n=14). OHR was performed in 1,383 (98%) and LHR in 34 (2%) patients. Subgroup analysis revealed no significant difference in age, ASA, and BMI and the presence/absence of 10 co-morbid conditions between OHR and LHR patients. Operative time was significantly shorter in OHR (3.7±1.7vs. 4.3 ±1.9 hr; p=0.05), but no LHR case received intraoperative blood transfusions 1.7% in OHR cases (p=0.17). No deaths occurred in the LHR group, and there was no difference in overall complications (OHR26% vs. LHR24%, p=0.74) or LOS (OHR9.6±10.4 vs. LHR8.6 ±7.5 days, p=0.15). Conclusion: In a high-risk Veteran population, HR can be performed with a lower mortality rate and comparable morbidity when compared with that previously reported in other patient populations.In our small subgroup, LHR was performed safely with no mortality, comparable complications and LOS, but with longer operative times.Abstract ID: 11Re-examining Penicillin Allergy Labels in the Perioperative Setting to Optimize Cefazolin Use: A Quality Improvement Pilot ProjectINTRODUCTION: Surgical patients with penicillin (PCN) allergy labels are more prone to receive second-line antibiotics for prophylaxis due to misinformation about cross-reactivity with cefazolin. However, cross-reactivity among beta-lactams derives from R side-chains and not the beta-lactam ring. Cefazolin has a unique R side-chain and is safe in most subjects with PCN allergy labels, with certain exceptions. Further, >95% of PCN allergy labels are now known to be erroneous. We sought to streamline the approach to PCN allergy labels in the perioperative setting to reduce the use of second-line antibiotics.METHODS: Baseline data was collected about use of cefazolin in PCN allergic surgical patients at the Atlanta VA Medical Center (AVAMC). An institutional algorithm was adopted to optimize antibiotic selection in PCN allergic subjects. Anesthesiology staff were presented with the algorithm and educated about the purpose of the quality initiative before project start date. Each week, the number of PCN allergic patients who were eligible to receive cefazolin and choice of antibiotic used for prophylaxis was documented. The safety of this approach was assessed via chart review of all patients who received epinephrine or diphenhydramine in the operating room.RESULTS: The % of patients receiving a first-line cephalosporin were compared before and after algorithm utilization. Over the 12-week project, 8.7% of patients (#45) that presented for outpatient surgery had PCN allergy label. 23 of the 45 patients were eligible to receive cefazolin and 65% (#15) received cefazolin without documented side effects such as rash, hypotension, or anaphylaxis. The most commonly used second-line antibiotics were vancomycin and clindamycin in equal proportion. CONCLUSION: Using a streamlined algorithm, we were able to significantly reduce the use of second-line antibiotics in PCN-allergic surgical patients without severe adverse reactions. Increasing use of cefazolin in PCN allergic patients is associated with better infection coverage and lower costs.Abstract ID: 12Elective Surgery for Diverticular Disease in U.S. Veterans: A VASQIP Study of National Trends and Outcomes from 2004 - 2018Introduction: Indications and techniques for elective surgery to treat diverticular disease have changed with time. Studies demonstrate a trend towards minimally invasive approaches with a decrease in postoperative complications. No study has investigated this subject in the Veterans Health Administration. This study’s objective was to compare practice patterns and outcomes in elective surgical management of diverticular disease in U.S. veterans over the past 15 years using the Veterans Administration Surgical Quality Improvement Project (VASQIP) database.Methods: Patients undergoing non-emergent surgery for diverticular disease were identified by ICD and CPT codes within the VASQIP database between 2004 and 2018. Demographics, comorbidities, operative approach, rates of ostomy creation, and postoperative complications were then compared using chi-square tests. The 15-year study period was divided into 3-year increments to assess changes over time.Results: A total of 4,719 patients were identified. Rates of open surgery decreased (83.4% to 51.2%, p Conclusions: Increased utilization of laparoscopy in veterans undergoing elective surgery for diverticular disease coincided with a significant decrease in rates of overall, infectious, and wound complications and a decrease in hospital length-of-stay. These trends mirror those reported nationally in non-veterans. The rates of complications and ostomy creation were higher in our cohort compared to non-veterans, which may be related to a higher incidence of comorbidities and tobacco use in veterans. Robotic surgery represents a small fraction of operations performed in this study.Abstract ID: 13Schlafen12 Reduces the Aggressiveness of Triple Negative Breast Cancer through Post-Transcriptional Regulation of ZEB1 That Drives Stem Cell DifferentiationIntroduction: Schlafen12 (SLFN12) is a cytosolic human protein that promotes human intestinal and prostatic epithelial differentiation. We sought to determine whether SLFN12 reduces triple-negative breast cancer (TNBC) aggressiveness. Methods: We validated bioinformatics analyses of publicly available databases by immunohistochemically staining human TNBC. After virally overexpressing or siRNA-reducing SLFN12 in TNBC cell lines, we measured proliferation by CCK-8 assay, invasion into basement-membrane-coated pores, mRNA by q-RT-PCR and protein by Western blotting. Flow cytometry assessed proliferation and stem cell marker expression, and sorted CD44+/CD24- cells. Stemness was also assessed by mammosphere formation, and translation by click-it-AHA chemistry.Results: SLFN12 expression was lower in TNBC tumors and correlated with survival. SLFN12 overexpression reduced TNBC MDA-MB-231, BT549, and Hs578T proliferation. In MDA-MB-231 cells, AdSLFN12 reduced invasion, promoted cell cycle arrest, increased E-cadherin promoter activity, mRNA, and protein, and reduced vimentin expression and protein. SLFN12 knockdown increased vimentin. AdSLFN12 reduced the proportion of MDA-MB-231 CD44+CD24- cells, with parallel differentiation changes. SLFN12 overexpression reduced MDA-MB-231 mammosphere formation. SLFN12 overexpression decreased ZEB1 and Slug protein despite increased ZEB1 and Slug mRNA in all three lines. SLFN12 overexpression accelerated MDA-MB-231 ZEB1 proteasomal degradation and slowed ZEB1 translation. SLFN12 knockdown increased ZEB1 protein. Coexpressing ZEB1 attenuated the SLFN12 effect on E-cadherin mRNA and proliferation in all three lines. Conclusions: SLFN12 may reduce TNBC aggressiveness and improve survival in part by a post-transcriptional decrease in ZEB1 that promotes TNBC cancer stem cell differentiation.Abstract ID: 14Monitoring Surgeon’s Mental Workload through Cerebral Oxygen Saturation: A Feasibility Study during Cardiac SurgeryIntroductionMental workload (MWL) is defined in terms of the interaction between the task and the individual performing that task. Previous work has explored providers’ objective MWL changes during standard cardiac surgery cases, using heart rate (HR) data from team members. Additional evidence supports near infrared spectroscopy (NIRS) as another method of quantifying MWL states during surgical tasks. The objective of this pilot study was to investigate the feasibility of measuring surgeons’ intra-operative MWL changes using both HR and NIRS data during a task categorized as teaching an inexperienced resident.MethodsDuring an aortic valve replacement procedure characterized by high teaching load, the attending surgeon was equipped with a HR sensor (Polar H10) and two NIRS sensors (Somanetics 5100C) applied on the forehead to collect left and right prefrontal cortex regional cerebral oxygen saturation (rSO2). Mean HR and rSO2 were time-synchronized and calculated for each minute of the procedure, resulting in 177 samples for each signal. Intra-operative events were annotated during the surgery, and superimposed onto a time-series of physiological data.ResultsCorrelational analysis revealed a significant positive relationship between Mean HR and rSO2, r(177)=0.67, p ConclusionsThrough this pilot study we have shown, for the first time, a significant correlation between Mean HR and rSO2 values during surgery. We have also demonstrated a high level of temporal sensitivity to MWL-induced changes in both HR and NIRS data. These findings lend support for a feasible approach to collecting multi-modal measures of MWL during surgery through unobtrusive, continuous sensor technology.Abstract ID: 15PREDICTORS OF RESPIRATORY MORBIDITY AND MORTALITY FOLLOWING ESOPHAGECTOMY: A MULTIVARIATE VASQIP ANALYSISIntroduction: Respiratory morbidity(RM) is common following esophagectomy and can negatively impact surgical outcomes. Patient and operative factors associated with RM following esophagectomy were studied to improve risk stratification and identify quality improvement targets.Methods: We analyzed 3872 esophagectomy cases in the VA Surgical Quality Improvement Program (VASQIP)(1998-2018). Multivariate analysis (MVA), using logistic regression, identified factors associated with RM and mortality. RM included: post-operative pneumonia, failure to wean from ventilator >48 hours, reintubation for respiratory failure.Results: RM occurred in 36% of esophagectomy patients. RM was associated with increased mortality(12% vs 2%), length of stay (median 24 vs 13 days), and re-operation(41% vs 13%, on univariate analysis).On MVA, factors independently associated with RM included: partial/complete functional dependency(OR 1.78,p 4 units(OR: 2.17,p On MVA, factors independently associated with decreased RM included: pre-op radiation therapy(OR: 0.67, p Over the study period, there was a significant decrease in RM. Notably, this reduction occurred without substantial changes in pre-op co-morbidity: smoking (44% vs 39%), COPD (20% vs 19%), diabetes (21% vs 24%), dyspnea (18% vs 15%), ASA class 4-5 (14% vs 20%) and partial/complete dependency (6% vs 4%).On MVA, factors independently associated with mortality included: metastatic cancer(OR: 2.58,P 4 units(OR: 2.5,P=0.023).Conclusion: The study identified factors which can guide patient optimization and risk stratification. Morbidity and mortality significantly decreased over the two decades, despite continued high patient co-morbidity. This improvement is possibly due to the VASQIP program. This is the largest study of patient and peri-operative factors associated with respiratory morbidity and mortality following esophagectomy.Abstract ID: 16Results of isolated Coronary Artery bypass grafting are not influenced by hospital Safety net Status.Introduction:Safety-net hospitals (SNH) are centers that provide care to a disproportionately high vulnerable population. We expect that SNH should provide comparable care for such index procedures like coronary artery bypass surgery, which is the most common adult cardiac surgical procedure in the United States. Thus, we compared adjusted post-operative outcome for CABG between SNH and non-safety net hospitals (non-SNH). Method and Results: We identified 1,872,737 adult isolated CABG procedures (mean age 66 years, female 27%) in the United States between January 2007 – October 2015. Among them, 333,035 (17%) had surgery at 1225 different SNH; 25% of institutions performing CABG in our study had safety-net status. SNH patients were more likely to have higher rates of heart failure, chronic kidney disease and be minorities. Unadjusted 30-day mortality (2% vs 1.73%; p Conclusion:Significant differences exist between patients undergoing CABG at urban safety-net and non-safety net institutions. However, safety-net centers provide outcome comparable to non-safety net centers in the United States.Abstract ID: 17Hospital-Level Correlation Between Perioperative Outcomes Used for Profiling Surgical QualityIntroduction: Risk-adjusted morbidity and mortality are used by the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP) to measure surgical quality across VA hospitals. However, the degree to which these outcomes correlate at the hospital-level is unknown. This information could help inform how these outcomes are used for quality monitoring or encourage development of pragmatic, alternative approaches to performance measurement. Methods: Retrospective cohort study of veterans who underwent inpatient, non-cardiac surgery (2014-2016) using VASQIP data. Hospital-level correlation between risk-adjusted 30-day morbidity and mortality was evaluated using Pearson’s correlation coefficient. Hospitals were also categorized into quintiles of risk-adjusted morbidity and mortality and the correlation between these rankings was assessed. Because mortality is an infrequently occurring outcome, risk-adjusted major morbidity, reoperation, and two composite measures (composite 1—mortality, major morbidity, and reoperation; composite 2—mortality and major morbidity) were also individually correlated with mortality to evaluate whether using more frequently occurring outcomes might be effective for profiling hospital performance. Results: Among 230,247 patients treated at 137 hospitals, there was low hospital-level correlation between various risk-adjusted outcome rates (highest r=0.40, mortality and composite 1; lowest r=0.32, mortality and morbidity). When hospitals were ranked into quintiles of risk-adjusted mortality and morbidity, 25.5% were high performers (i.e.: quintile 1) and 2.1% were low performers (i.e.: quintile 5) for both outcomes. Across each of the 6 risk-adjusted measures, 18.3% of hospitals were in the top quintile and 1 hospital was in the bottom quintile for all outcomes. Conclusions: Correlation between hospital-level perioperative morbidity and mortality rates is generally low, suggesting these outcomes capture different domains of surgical quality. Furthermore, while composites of currently measured outcomes may be an efficient way to improve statistical power relative to mortality alone, further work is needed to understand whether they provide a more robust and accurate picture of hospital performance and quality.Abstract ID: 18Gender disparities among young surgeons during transition into practice: A nationwide surveyIntroduction: Female surgeons face unique professional challenges. However, research to date has not investigated gender-specific experiences during transition from surgical training into the surgical workforce. Our study was designed to examine the gender-related differences during the transition into practice of young surgeons.Methods: A nationwide paper-based survey regarding the transition in practice experience was mailed in August 2019 to general, colorectal, vascular, and cardiothoracic surgeons that became members of the American College of Surgeons within the last 5 years.Results: A total of 853 of 2915 surveys were completed (29.3% response rate). The mean age of respondents was 42.4 ± 1.5 years, mean graduation age was 35.1 ± 1.2 years, and mean interval since graduation was 7.26 ± 0.2 years. The majority (62.0%) of respondents were males. The number of female surgeons reporting an inadequate overall transitioning experience was significantly higher than males (38.0% vs 21.7% respectively; p< 0.05). The number of female surgeons leaving their first job was significantly higher than males (48.2% vs 41.8% respectively; P < 0.05). Significantly more females than males reported receiving inadequate institutional support during their transition into practice (51.2% vs 41.6% respectively; p < 0.05). The number of female surgeons receiving mentorship on their first job was significantly lower than males (66.7% vs 74.6% respectively; p < 0.05). Female surgeons were significantly more willing to have a retired surgeon as a mentor when compared to male surgeons (54.3% vs 36.5% respectively; p < 0.05). Conclusion: Our findings suggest that new female surgeons feel left behind during the transition into practice. When compared to male surgeons, they report having a worse experience, and receiving less institutional support and mentoring during the transition into practice. Recognizing these gender disparities can help design successful strategies to improve the transition into practice for all surgeons.Abstract ID: 19The cost of surgical futility – an analysis of emergent end-of-life care.Introduction: Emergency surgery in high risk patients results in high mortality. Many patients die within the immediate post op period and the cost of such care and impact on the patient’s quality of life prior to death is largely unknown. The aim of this study is to analyze the cost of futile surgery and the quality of life prior to early postoperative death.Methods: We queried the National Inpatient Sample (NIS) from 2012-2014 for patients who underwent an emergency partial colectomy (PC), total colectomy (TC), or small bowel resection (SBR) and died during the same hospital stay. Major outcomes of interest included cost, length of stay (LOS), and markers of quality of end-of-life (QOL) defined by 4 diagnoses – respiratory failure, septic shock, cardiac arrest, and altered mental status. Descriptive and univariate statistics were utilized as appropriate.Results: In total, 4130 patients were analyzed (PC: 2360; TC 406; SBR: 1364). Greater than 85% of patients (PC: 87.5%; TC: 89.41%; SBR: 86.07%) were considered to have an extreme likelihood of dying as defined by NIS. The mean (SD) cost of care was $178, 339 ($193, 352) for PC, $166,688 ($151, 998) for TC, and $180,083 ($220,632) for SBR. The mean LOS (SD) prior to death was 12.5 (13.6) days for PC, 10.3 (9.7) days for TC and 12.2 (14.4) days for SBR. More patients experienced sepsis and respiratory failure after TC (82.76%, 55.42) compared to PC (72.97%, 46.27%) and SBR (69.43% 44.79%). Similar number of patients experienced cardiac arrest (11.82%, 11.74%, 11.95%) and altered mental status (6.16%, 5.64%, 7.11%) after these three procedures.Conclusions: High risk patients who died after EGS expended significant cost and suffered poor quality-of-life prior to death. This study highlights the importance of identifying surgically futile patients, and the need for further data to help guide preoperative discussions.Abstract ID: 20Percutaneous Endovascular Aortic Repair (PEVAR) under Monitored Anesthesia Care Yields Decreased Operative Time, Length of Stay and complications when Compared to PEVAR Under General AnesthesiaIntroduction: Percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) can be performed under Monitored Anesthesia Care (MAC) with local anesthesia or general anesthesia (GA). Several factors, including patient preference and surgeon comfort influence anesthesia selection. This study reports our experience and outcomes of PEVAR performed under MAC vs. GA.Methods: PEVAR recipients between 2010-2019 for abdominal aortic aneurysms were included. Patients were excluded if they had fenestrated, branched grafts, or if additional procedures were performed during the operation such as lower extremity revascularizations. Demographics, operative statistics, and postoperative data were analyzed. Independent-samples t-tests and chi-square analyses were calculated.Results: 129 patients were identified, and 114 PEVAR were included with 51 (44.7%) performed under MAC and 63 (55.3%) performed with GA. 15 (11.6%) patients were excluded as they began percutaneously but were converted to femoral cutdowns. 1 (0.9%) PEVAR was converted from MAC to GA due to patient comfort. Comparing MAC vs. GA, there was no difference in median age (69 vs. 68, p=.344), comorbidities (2.5 vs. 2.8, p=.349), graft brand (p=.834), or contrast delivered (85.7 vs. 83.6mL, p=.825) but a significant difference in procedure time (110.2 vs. 135.4 minutes, p<.001) and total time in the operating room (167.9 vs. 249.0 minutes, p=.016). There was a trend towards significance, comparing MAC vs. GA, in blood loss (137.9 vs. 174.2mL, p=.213), hospital length of stay (1.9 vs. 2.8 days, p=.068), and 30-day complications (3.9 vs. 12.7%, p=.100).Conclusion: PEVAR with MAC and local anesthesia, compared to GA, requires less procedure and total operative time, leads to less blood loss, and yields decreased length of hospital stay with fewer postoperative complications. When possible, PEVAR under MAC should be favored over GA. Patient selection, coordination between the anesthetist and surgeon, and surgeon’s training and comfort with percutaneous endografting play an important role in successful interventions.Abstract ID: 21Telehealth Integration for Endovascular Aortic Repair Allows for Adequate Care and Follow-up: A Single Center Retrospective ReviewIntroduction: Preoperative planning, perioperative care, and long-term surveillance are key for a successful aortic program. This study aims to demonstrate the feasibility and safety of a remote endovascular abdominal aortic repair (EVAR) program, preparing patients preoperatively and following them postoperatively at the referring center, with complications managed safely from a distance via a telehealth program.Methods: All patients referred for an EVAR between 2015 and 2019 from a regional Veterans Administration (VA) hospital, without an aortic program, were included. Anesthesia, access, graft brand, demographics, operative information, postoperative data, and complication information were analyzed. Results: 73 patients underwent operations at our institution with follow-up at a neighboring VA hospital via telehealth. Median age was 69, and 28 (38.4%) underwent percutaneous EVAR (PEVAR) with monitored anesthesia care, 29 (39.7%) underwent PEVAR with general anesthesia, and 16 (21.9%) underwent EVAR with femoral artery cutdown. Complications Clavien-Dindo Grade I and II (seroma, decubitus ulcer, and tachyarrhythmias requiring only medications) occurred in 5 (6.8%) patients, and complications Clavien-Dindo Grade III-V (pseudoaneurysm requiring bedside injection, groin infection requiring incision and drainage, peripheral ischemia requiring revascularizations, a colectomy required for ischemic colitis, and one postoperative death) occurred in 8 (11.0%) patients. Of those, most were discovered and treated while inpatient at the operative facility. After discharge, 2 (2.7%) patients required readmission at operative facility for additional procedures, and 2 (2.7%) could be managed remotely, via telehealth at the outside VA.Conclusion: Remote EVAR programs can effectively be conducted across institutions with telehealth integration to monitor postoperative outcomes. Patients can be safely followed postoperatively and easily transferred back to the primary institution if more specialized care or operative interventions are required. The key to successful telehealth programs is a dedicated team at the referring center and a continuous direct line of communication between the referring and receiving centers.Abstract ID: 22Impact of Smoking Cessation on Thirty-Day Postoperative Outcomes in U.S. Veterans Undergoing Lobectomy for Lung CancerIntroduction: Numerous studies have highlighted the adverse effects of tobacco use on postoperative outcomes. While smoking cessation is associated with overall improvement in health status, data on the effects of cessation shortly before lung surgery is mixed. This study compares outcomes after lobectomy between active smokers, recent quitters and nonsmokers.Methods: Patients undergoing lobectomy for cancer at national Veterans Affairs medical centers from 2012-2018 were retrospectively identified by CPT and ICD codes in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. The sample was stratified into three groups: smokers within two weeks of surgery (“active smokers”), those who quit between two weeks and three months prior to surgery (“recent quitters”), and all others (“nonsmokers”). Multivariable logistic regression analysis was performed to compare outcomes between groups. Results: Nonsmokers were significantly older with higher body mass index and higher proportions of diabetes, hypertension, and cardiovascular disease(p < 0 .05). Smoker groups had higher rates of alcohol/drug use and lung disease(p < 0 .05). Relative to active smokers, recent quitters had lower odds of VASQIP complications and failure to wean from ventilator(p < 0 .05). Relative to nonsmokers, recent quitters had no significant outcome differences. Relative to nonsmokers, active smokers had significantly higher odds of pulmonary complications (failure to wean from ventilator, pneumonia, reintubation), acute renal failure, and urinary tract infection(p < 0 .05). When lobectomy was performed using thoracoscopic technique, there was no difference in outcomes between active smokers and recent quitters.Conclusion: Contrary to previous reports, smoking cessation as recent as two weeks prior to lobectomy for lung cancer may be associated with fewer complications than active smoking at the time of surgery. Nonsmokers have fewer pulmonary and infectious complications compared to active smokers despite more preoperative comorbidities, and recent quitters show a trend toward the risk profile of nonsmokers. Further studies are needed to further delineate the temporal effect of quittingAbstract ID: 23Postoperative Outcome of Ventral Hernia Repair in VeteransIntroduction: Ventral hernia repair is one of the most common operations with variable outcome reports with reported mortality rate 15-37% and mortality rate 0.3-1.4%. This study examines the postoperative outcome of Open and Laparoscopic Ventral Hernia Repair (OVHR)/(LVHR) in veterans.Methods: The Veterans Affairs Surgical Quality Improvement Program was queried for all ventral hernia repairs during the period 2008-2015. Data collection included patient demographics, operative details, and postoperative outcomes. Univariate and multivariate regression analyses were used and p-value of ≤0.05 was considered significant.Results: A total of 19,883 patients were identified [92.6% males, mean age 59.65 years, mean BMI 31.1 with 53.1% morbidly obese (BMI ≥30), 97.4% functionally independent, 71.6% with ASA class ≥III, 31.6% active smokers]. Overall mortality rate was 0.5% (95), morbidity rate was 6.5% (1289) [superficial Surgical Site Infection (SSI) 1.9%, Deep SSI 0.6% and reoperation rate 3%], mean postoperative Length of Stay (LOS) was 4.37 days. OVHR was performed in 60.2% and 39.2% LVHR, 6.7% were emergency procedures and mean operative time was 1.76 hours. Univariate analysis showed LVHR group has higher mean BMI (30.7±6OHVR vs. 31.6±6LVHR, p<0.001), lower ASA class≥III(74.1%OVHR vs. 68.8%LVHR, p<0.001), less like to be emergently performed (4.6%OVHR vs. 1.6%LVHR, p<0.001), longer operative time (1.7±1.2OHVR vs. 1.8±1LVHR, p<0.001), lower complications rate (7.5%OVHR vs. 3.9%LVHR, p<0.001), lower mortality rate (0.6%OVHR vs. 0.29%LVHR, p=0.002) and shorter LOS (4.9±5.9OHVR vs. 3.39±3.8LVHR, p<0.001). BMI ≥35 was associated with increased superficial SSI (p<0.001), venous thromboembolism (p=0.02), cardiac arrest (p<0.001), and reoperation (p<0.001), while BMI<18.5 group had longer LOS (6.4±9.7 days, p=0.003). The negative impact of BMI≥35 was only found in patient undergoing OVHR (p=0.033) NOT in LVHR (p=0.36).Conclusion: LVHR is superior to OVHR in regards to short outcomes and shorter LOS especially ina high risk population. BMI ≥35 is a risk factor for superficial SSI and reoperation in patient undergoing OVHR.Abstract ID: 24The Differences in Mitochondrial Dysfunction Between Ex vivo And In Vivo Myocardial Global Ischemia Models: Implications for Donation After Circulatory Death ResearchIntroduction: Heart transplantation (HTx), is limited due to available donor hearts, which primarily come from donation after brain death (DBD) donors. Donation after circulatory death (DCD) donors can expand the donor pool, but ischemic injury limits their use. Mitochondrial are the primary sites of ischemic injury, majority of studies examined ischemic injury based on ex vivo model while DCD ischemia is an in vivo process. We sought to examine the differences between in vivo and ex vivo ischemia on mitochondrial function.Methods: Under pentobarbital general anesthesia rats (n=5) underwent in vivo ischemia based on clinical DCD process with ischemia time of 25 minutes. Under anesthesia nine rat hearts were procured with no in vivo ischemia but were subjected to 25 minutes of ex vivo ischemia on Langendorff circuit. Five DBD and 11 time control hearts served as controls for in vivo and ex vivo groups respectively. Two groups of mitochondria, subsarcolemmal (SSM) and interfibrillar (IFM) were isolated from hearts, oxidative phosphorylation (OXPHOS) and calcium retention capacity were measured. Data was analyzed using a one-way analysis of variance (ANOVA). Results: Both ex vivo and in vivo ischemia significantly damaged OXPHOS function of SSM and IFM; however, for the same duration of ischemia the proportion of damage was significantly higher with ex vivo ischemia. Among the control hearts, time control hearts showed decrease OXPHOS compared to DBD hearts; however, the differences did not attain statistical significance. The CRC was equally decreased with ex vivo and in vivo ischemia.Conclusion: For the same duration of ischemia, ex vivo hearts sustain higher amount of injury to mitochondrial OXPHOS function compared to in vivo hearts. The possible reason(s) could be the gradual onset of ischemia and the presence of adaptive mechanisms in in situ group. Also, the ex vivo group likely incur additional reperfusion injury.Abstract ID: 25"Triple-Therapy" approach improves outcomes in patients with recurrent and persistent carpal tunnel syndromeIntroduction: Various procedures have been described for patients undergoing a revision carpal tunnel release. These can include repeat open decompression with external or internal neurolysis, tenosynovectomy, endoscopic release, various flap techniques, saphenous vein wrapping and use of prosthetic implants. This study reports a case series of 30 consecutive patients who underwent revision carpal tunnel release at single institution from 2012 to 2018 involving a combination of three techniques (triple therapy approach): neurolysis (external or internal) and tenosynovectomy, collagen matrix conduit wrap (NeuraWrap; Integra Lifesciences or Axoguard Nerve Protector, AxoGen Inc.), and hypothenar fat flap. Materials and methods: The index surgeries were performed by a variety of surgeons at private institutions and at the VA hospital. However, all revision interventions in this series were performed by the senior author (Z.J.P.) Demographic data were collected. Subjective outcomes, complications, and mean VAS scores were recorded pre and post-operatively. VAS scores were compared using a paired-t test. Statistical analyses were performed with SPSS 20 (IBM, Chicago, IL). Results: All patients presented with recurrent or persistent symptoms of pain, numbness, and paresthesia. Patients with carpal tunnel syndrome had a mean motor latency of 5.5 millisec and a motor conduction velocity of 44.4 m/s in their nerve conduction testing. The mean time period between index carpal tunnel surgery and revision was 8 years (Range 1-25 yrs). Of the 30 patients who underwent surgery for persistent or recurrent carpal tunnel syndrome, symptoms resolved completely in 25 patients. 2 patients were lost to follow up. 3 patients showed no improvement. The mean preoperative VAS score was 4.37 and declined to 1.23 after surgery (p <.0001). Conclusion: Our study demonstrates that the combination of neurolysis and tenosynovectomy along with a nerve wrap and hypothenar fat flap results in excellent outcomes in patients with recurrent or persistent carpal tunnel syndrome.Abstract ID: 26Inhibition of TGF-b in the Tumor Microenvironment Potentiates Mesothelin-Chimeric Antigen Receptor NK-92MI-Mediated Killing of Pancreatic Cancer CellsIntroduction: Although mesothelin-chimeric antigen receptor (MSLN-CAR) T cells kill pancreatic cancer (PC) cells in vitro, their activation in the clinical setting is often compromised by the tumor microenvironment (TME). Previously, we demonstrated a significant reversal of TME-mediated inhibition of MSLN-CAR T cell activity against PC cells either by depleting TGF-b in autologous T cells or by using the MSLN-NK-92MI CAR T cell line which secretes IL-2. In this study, we combined both of these approaches to further overcome TME-mediated inhibition of the ability of CAR T cells to kill PC cells. Methods: Tumor-conditioned medium (TCM) simulating the TME was obtained from 48 h serum-free cultures of target BxPC-3 human PC cells with or without TGF-b depletion. MSLN-CAR vectors were electroporated into NK-92MI cells. IFN-g/granzyme B secretion were measured by an ELISA kit and cytotoxicity by MTT assay. Results:?When compared with mock electroporation, ELISA co-culture assays of MSLN-NK-92MI CAR T cells with BxPC-3 target cells demonstrated robust secretion of IFN-g?and granzyme B, both of which are crucial for the induction of cell death. We observed significant TCM-mediated inhibition of IFN-g?(p<0.01) and granzyme B (p<0.01) secretion in the same co-cultures, which was partially restored when TCM was TGF-b?depleted?(p<0.05 for both cytokines). Assays of BxPC-3 with MSLN-NK-92MI CAR T cells demonstrated cytotoxicities of 75% (p<0.01) and 90% (p<0.01) at E:T ratios of 10:1 and 20:1, respectively, when compared with control.?Addition of TCM to the co-cultures reduced these cytotoxicities to?17% (p<0.01) and 22% (p<0.05), respectively.?However, TGF-b?depletion from TCM blunted?this reduction by increasing these cytotoxicities back to 42% (p<0.05) and 55% (p<0.05), respectively.?Conclusions:?The ability of IL-2-secreting MSLN-NK-92MI CAR T cells to kill PC cells may be further enhanced by depleting TGF-b?from the local tumor microenvironment, potentially allowing for more effective clinical translation.Abstract ID: 27Using Patient Feedback to Promote Patient-Centered Care by Physicians through Behavioral Economics: A Feasibility StudyIntroductionA key goal for the VA system is to provide patient-centered care to Veterans, but VA surgeons face growing pressure to see more Veterans in clinic and perform more operations. Consequently, surgeons may have less time to spend building patient-centered relationships with Veterans and learning to address their care needs. This study evaluated Veteran expectations of patient-centered care by surgeons and how well surgeons provide such care. We also measured whether Veterans would be willing to participate in a pilot study that promoted patient-centered care based on their feedback of surgeon performance.MethodsWe administered 2 validated surveys to pre- and postoperative Veterans in the surgical oncology clinic at our VA to measure (1) patient expectations of patient-centered care, and (2) delivery of patient-centered care. We also evaluated willingness to provide feedback on how surgeons could better provide patient-centered care if that information affected the surgeon’s bonus.ResultsWe recruited 48 Veterans with median age of 65 years, and 85% had either colorectal, liver, or pancreatic cancer. In all, 88% were men, 71% were Caucasian, and 27% African-American. Veterans had high expectations for delivery of patient-centered care, with a median score of 6.5 on a 7-point Likert-type scale. Surgeons provided a high degree of patient-centered care, with a median score of 5 on a 5-point Likert -type scale. We found that 90% of participants were comfortable providing feedback related to patient-centered care, knowing that the information would affect their surgeon’s bonus.DiscussionVeterans have high expectations regarding the delivery of patient-centered care, and most Veterans would be willing to provide feedback that would have financial implications for surgeons. Our findings suggest that a pilot study using financial incentives to promote patient-centered care for Veterans is feasible.Abstract ID: 28Using Local Rather Than General Anesthesia for Inguinal Hernia Repair May Significantly Reduce Complications for Frail VeteransIntroductionFrailty is characterized by loss of physiologic and cognitive reserves, predisposing patients to increased anesthetic sensitivity and significantly worse postoperative outcomes. Since inguinal hernia repair is the most common general surgery operation performed in the VA system, we evaluated whether using local rather than general anesthesia for hernia repair could mitigate effects of frailty on postoperative recovery. We hypothesized that use of local rather than general anesthesia would be associated with reduced postoperative complications among frail veterans who underwent inguinal hernia repair.MethodsWe used the Risk Analysis Index to identify 8,038 frail veterans (Risk Analysis Index ≥ 30) from the VA Surgical Quality Improvement Program who had open elective inguinal hernia repair under local or general anesthesia from 1998-2018. We used generalized estimating equations to measure effects of local anesthesia on postoperative complications, controlling for clustering within hospitals and adjusting for known confounders.ResultsOur cohort included 5,188 veterans having inguinal hernia surgery under general anesthesia and 2,850 under local. Local anesthesia was associated with a 48% reduction in postoperative complications (OR 0.52, 95% CI 0.38-0.72, p DiscussionFor frail veterans having inguinal hernia surgery, choosing local rather than general anesthesia is associated with nearly 50% reduction in postoperative complications. Given the paucity of interventions that improve outcomes in frail veterans, there is an urgent need for a randomized trial comparing effects of local versus general anesthesia in this vulnerable population.Abstract ID: 29Local Anesthesia May Improve Outcomes for Frail Veterans Undergoing Umbilical Hernia RepairsIntroductionSurgeons in the United States perform 200,000 umbilical hernia repairs annually. Although the operation can be performed under local or general anesthesia, the optimal approach remains unclear. We hypothesized that using local rather than general anesthesia for umbilical hernia repair in Veterans would reduce complications and operative time, and these benefits would be greatest among frail Veterans.MethodsWe used data from the 1998-2018 VA Surgical Quality Improvement Program to identify Veterans aged 18 years and older who underwent elective open umbilical hernia repair under local or general anesthesia. Our primary outcomes was incidence of postoperative complications. Secondary outcomes included operative time and time in the postoperative anesthesia care unit (PACU). We used multivariable logistic and linear regression with cluster robust standard errors to adjust for known confounding and clustering within VA centers. Veterans were categorized as frail if their Risk Analysis Index score was ≥ 30.ResultsThere were 36,947 Veterans who underwent umbilical hernia repair during the study period, and 4,958 (13%) of those used local anesthesia. Local anesthesia was not associated with fewer postoperative complications but was associated with a 24% decrease in operative time (95% CI 29%-19%) and a 26% shorter PACU stay (95% CI 34%-18%). For frail Veterans, local anesthesia was associated with an 86% decrease in complications (OR 0.14, 95% CI 0.03-0.72), a 28% decrease in operative time (95% CI 35%-22%) and a 31% decrease in PACU stay (95% CI 48%-13%). ConclusionOur observational study suggests that using local rather than general anesthesia for umbilical hernia repair may significantly decrease operative and PACU times for all Veterans and dramatically reduces postoperative complications for frail Veterans. Given the dearth of interventions that improve outcomes for frail Veterans, there is an urgent need for a randomized trial to confirm our findings.Abstract ID: 30Implementing a Pathway for the Safe Reduction of Opioids in Patients Undergoing Robotic Assisted Laparoscopic Prostatectomy (RALP): A Retrospective Analysis of a US Veterans Affairs Medical Center Patient CohortIntroduction:Opioids are commonly used for post-operative pain control although they have numerous side effects. Our objective was to safely reduce opioid use following RALP. Methods:A single-institution quality improvement project (QIP) was initiated. Prior to implementation, low-volume local anesthesia (LA) was used, and patients generally received oral opioids for pain control with IV opioids available as needed. With the new pathway, LA was administered by the surgeon, both subcutaneously and into the transversus abdominis plane around each incision. Acetaminophen was scheduled, as was ketorolac if GFR>60ml/min. Depending on surgeon preference, patients used opioids or ibuprofen for breakthrough. Outcomes were analyzed for cases performed over a 19-month period. Statistical significance was achieved at p-value Results:157 patients undergoing RALP were included in the retrospective analysis, with 76 in the opioid-free (OF) pathway. There was no significant difference between OF and standard (S) groups for age, opioid prescription within 1 year before surgery, or history of alcohol or substance abuse. LA was used in 37% of S cases, and smaller amounts were used (10.7mL or 0.3mg/kg) compared to OF cases (58.6mL or 1.7mg/kg). Bupivacaine 0.25% was used in all except four cases. 93.4% of patients in OF pathway did not require opioids post-operatively, compared to 24.7% of patients in the S pathway (p<0.001). Pain scores were lower on POD 0-2 for OF patients, who rated their pain 1.5-1.9 points lower for each day (p<0.001 for each). All S pathway patients had a drain, compared to 7.9% of patients in OF pathway. Post-operative complication rate was lower in the OF group (0% compared to 6.2%, p=0.028), and there was no difference in readmission rates between groups.Conclusions:This QIP demonstrates that post-RALP opioid use and pain scores can be safely and significantly reduced with use of LA infiltration plus non-opioid medications.Abstract ID: 31Gender, racial and ethnic disparities in morbidity after pancreaticoduodenectomy and distal pancreatectomy for cancerIntroduction: We have previously observed racial and ethnic disparities in resection rates for pancreas cancer. Nevertheless, neither gender, race nor ethnicity impact long-term survival after pancreatic cancer resection. This study aimed to evaluate associations of gender, race and ethnicity with short-term outcomes after pancreatic resection for malignancy.Methods: Pancreaticoduodenectomies and distal pancreatectomies for cancer between 2014 to 2017 were selected from the ACS-NSQIP database. A published definition of major morbidity based on type of complication was utilized. The chi square test was used for univariable analysis. For multivariable analysis, hierarchical binomial logistic regression was used with short-term outcomes entered after models based on pre-operative patient, tumor and pancreas-specific variables were established. Results: 15,223 patients who underwent pancreaticoduodenectomy and 7,781 patients who underwent distal pancreatectomy were identified. On univariable analysis, morbidity and major morbidity after pancreaticoduodenectomy were associated with male gender (35.2 vs. 31.7%, p <0.01 for morbidity and 28.4 vs. 23.5%, p<0.01 for major morbidity), Asian race (37.4 vs. 30.3%, p<0.01 and 32.0 vs. 24.8%, p<0.01), and Hispanic ethnicity (37.3 vs. 31.8%, p<0.01 and 30.0 vs. 24.6%, p<0.01), while morbidity and major morbidity after distal pancreatectomy were associated with male gender (24.5 vs. 20.8%, p<0.01 and 20.8 vs. 15.6%, p<0.01). On multivariable analysis, morbidity after pancreaticoduodenectomy was independently associated with Asian race (p=0.02) and Hispanic ethnicity (p=0.02), while major morbidity after pancreaticoduodenectomy was associated with male gender (p <0.01) and Asian race (p=0.01). Gender, race and ethnicity were not independently associated with morbidity and major morbidity after distal pancreatectomy. Black race was not associated with short-term outcomes after pancreatic resection for cancer. Conclusion: After pancreaticoduodenectomy for cancer, Asian race and Hispanic ethnicity are independently associated with morbidity, while male gender and Asian race are independently associated with major morbidity. Further studies are warranted to determine the basis of these associations.GROUP 2Abstract ID: 32Post-Cholecystectomy Gallstone Ileus: A Systematic reviewINTRODUCTIONGallstone ileus is an unusual complication of cholelithiasis. The classical etiology is the result of stone impaction in the terminal ileum originating from a cholecystoduodenal fistula as a result of cholecystitis. However, exceptions to this pathophysiology have been noted in every single step. The most uncommon exception is the absence of the gallbladder in the setting of gallstone ileus. METHODSWe performed an extensive review of post-cholecystectomy gallstone ileus following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The literature search was performed in December 2019 and included multiple databases. This was inclusive of forty-nine separate cases and report eight different mechanisms leading to this unusual complication. RESULTSThe most common mechanism is a lost stone during cholecystectomy that then erodes through the intestinal wall leading to bowel obstruction. Our review showed a predominance of women (64.0%) at an average age of 68.0 years. Delay in diagnosis was the rule (64% of cases) with the correct diagnosis only made in 37.5% of patients during admission. Pneumobilia was reported in 29.0% of the cases. There was a wide range in delay of presentation between cholecystectomy and gallstone ileus from 10 days to 50 years (mean 12.4 years). CONCLUSIONSPost-cholecystectomy gallstone ileus in an exceedingly unusual complication of cholelithiasis, patients have a highly atypical presentation and are older with a burden of comorbid conditions, but surgical intervention is required. Retrieval of stones should be aggressively undertaken if they are spilled during cholecystectomy. Owing to the increasing age of the American patient population, it is likely that a higher number of patients with this condition will be encountered.Abstract ID: 33Minimizing the Risk – Analysis of GRIT in Surgical Residents and their Reaction to a Medical Malpractice Claims Curriculum.INTRODUCTION: Teaching the medical malpractice claims (MMC) process is crucial for general surgery residents. GRIT has been defined as a “passion and perseverance for long-term goals” and has been validated into an eight-question GRIT assessment survey (GAS).We sought to examine how GRIT differentiated our surgical resident reactions to a MMC educational program. METHODS: A pre and post educational survey was given to general surgery residents attending a MMC educational program in December 2019. All residents were also assessed with GAS and differentiated into High GRIT (score 4 or 5) or Low GRIT (< 4). They were asked to assess on a five-point Likert scale a key question before and after the lecture in two different roles (resident and future as an attending): “I am worried about being involved in a legal matter as a resident/attending.” This mean change or “?” was assessed for both of these questions and compared between High and Low GRIT resident groups. T-test was used to assess mean differences. RESULTS: Eighteen residents responded to the survey. Low GRIT Residents (n=13) had lower PGY level (2.1 ± 1.0 vs. 3.3 ± 1.7;p=0.06) and greater ? Reported Resident Role Anxiety (0.6 ± 0.7 vs. 0.3 ± 0.4;p=0.03) compared to High GRIT Residents (n=6) respectively. There was no difference in ? Reported Attending Role Anxiety between the two groups.CONCLUSIONS: We have found that the impact of awareness of legal issues and learner’s fear of interacting with the legal system was greater in those residents with lower measured GRIT. These data should guide future efforts of potentially assessing GRIT and devising curricula focused to different GRIT resident levels.Abstract ID: 34#ILookLikeASurgeon: What are the Delayed Trends of This Social Media Trend?INTRODUCTION: The “#ILookLikeASurgeon” (LLAS) campaign on Twitter was the beginning of a movement that empowered female surgeons to express themselves and increase their visibility in a historically male dominated field. To date there are over 500,000 LLAS tweets. We set forth to examine the impact of these Tweets in 2019 some two years after the initial launch of the trend.METHODS: Twitter was examined in November 2019 for LLAS tweets from 1/1/2019 to 7/1/2019. Tweets were filtered by 100 likes, as a minimum limit of engagement and examined for gender of tweeter, date tweeted, geography and content. Tweets were examined by a single viewer (MW) and Microsoft Excel was used to compute the results.RESULTS: A total of 59 tweets containing the LLAS hashtag were examined. Each tweet had an average of 400 ± 475 likes and 62 ±122 retweets Approximately 90% of the tweets examined were posted by females. Additionally, we found broad distribution of geographical locations with the United States averaging 66% of the tweets. Interestingly, 93% of the tweets used the hashtag to promote gender equality and 7% of the tweets used it to promote ethnic equality in surgery. Finally, we found 90% of the tweets with the hashtag depicted a day in life (lifestyle content) of a surgeon. Whereas, the other 10% of the tweets with the hashtag were educational (educational content) in content.CONCLUSIONS: Our study indicates that tweets containing LLAS obtained a large amount of social engagement. The majority of tweets were by females, expressing their day in a life as a female surgeon. The hashtag was used to promote both gender and ethnic equality in the field of surgery. It is important to acknowledge that gap and address underlying issues as to why women are underrepresented in the surgical field.Abstract ID: 35Comparative Effectiveness of Risk-Adjusted CUSUM and Episodic Hospital Surgical Performance EvaluationIntroduction: The VA Surgical Quality Improvement Program (VASQIP) uses quarterly (i.e.: episodic) evaluation to identify VA hospitals with outlier performance. However, the time lag between within quarter performance decline and hospital notification at quarter end is an inherent limitation. Analytic approaches that could identify declining performance in more real-time could enhance VA’s surgical quality improvement (QI) efforts.Methods: Hospital-level analysis of 104 VA hospitals using VASQIP data (2011-2016) comparing identification of poor performing 30-day mortality outliers using two approaches: 1.) risk-adjusted observed-to-expected (O-E) ratios; 2.) risk-adjusted cumulative sum (CUSUM) with V-mask (defined by a radius and a slope to ascertain the rate at which performance is declining). V-mask slopes of 0.6-3.0 and radii of 0.5-3.0 were evaluated. Lag time for outlier identification (i.e.: time from in quarter CUSUM detection date to end of quarter O-E detection date) and ‘at-risk’ (i.e.: after CUSUM signal, but before quarter end) cases and inpatient postoperative days were calculated.Results: Negative predictive value for CUSUM relative to episodic O-E was excellent for all V-mask thresholds (≥90%). Compared to episodic O-E, CUSUM identified outlier hospitals approximately halfway into a quarter (median of 47-49 days, depending on the V-mask used) which translated into a median of 129 [IQR 60-187] VASQIP cases and 368 [IQR 145-681] postoperative inpatient days at-risk. At hospitals identified as outliers by CUSUM but not O-E, there were clusters of 30-day mortalities (median 2 deaths [Interquartile Range 1-4]) leading up to the CUSUM with some clusters extending beyond the CUSUM detection (median 2 deaths [Interquartile Range 1-8]).Conclusions: CUSUM could serve as a useful tool to provide VA hospitals with an early warning at a time when performance is declining instead of when it has already reached an unacceptable level. This information could provide opportunities for hospitals to proactively (as opposed to reactively) engage in local QI.Abstract ID: 36The prevalence of resident autonomy in general surgery training: a NSQIP analysisIntroductionResident autonomy in surgical training is paramount to independent practice. The prevalence of independent operative ability in graduating residents is unknown. Our aim was to determine the prevalence of general surgery resident autonomy for emergency general surgery operations and to identify trends with time.MethodsWe queried the ACS-NSQIP database from 2005 to 2016 for patients undergoing one of 7 emergency general surgery operations including: partial colectomy, small bowel resection, cholecystectomy, peptic ulcer surgery, lysis of adhesions, appendectomy and exploratory laparotomy. We evaluated the trend of resident involvement over the study period. Other outcomes of interest were: operative time, 30-day-mortality and complications. Resident involvement was a unique, legacy variable. We defined autonomy as a resident operating alone, without an attending scrubbed. ResultsData regarding resident involvement was available for 2005-2010. These data were missing for 44% of cases in 2011 and 77% of cases in 2012. No resident involvement data was collected for 2013-2016. A total of 90,790 operations were performed between 2005-2010. Residents operated autonomously in 922 cases (1%). There was a trend to reduced resident autonomy over time (2005-2010, p=0.85). Resident autonomy was significantly associated with a longer composite operative time (65 v 58 min p<0.001) and lower risk of sepsis and septic shock (p=0.01). Resident autonomy was not associated with increased risk of complications or mortality.ConclusionComplete resident autonomy is rare and becoming less common, even with increasing attention to its importance. Resident autonomy is not associated with increased complications nor mortality. Need exists for an ongoing national registry collection of resident involvement to better understand the role of autonomy on outcomes.Abstract ID: 37The Key to Combat Readiness: A Strong Military-Civilian PartnershipIntroduction: Of the >1M military hospital admissions in 2018 Methods: During a three-year period, all FRSTs rotating through the Army Trauma Training Department (ATTD) at the Ryder Trauma Center were surveyed. Respondents were divided by Military Occupational Specialty (MOS) and whether they were AD or AR. Results: 467 surveys were distributed with 424 responses (91%) including 100 AR and 324 AD. MOSs included 66F (CRNA, n=76), 66S (critical care nurse, n=47), 66T (OR nurse, n=55), 68C (LPN, n=102), 68D (OR tech, n=25), and 68W (combat medic, n=166). AD and AR did not differ in military experience; total deployments (58 % vs. 65% at least once, p=0.114), combat deployments ( 50% vs. 59% at least once, p=0.132), peri-deployment medical workload (52% vs. 62% patient contact, p=0.124), and FRST tenure length (53% vs. 60% > 6 months, p=0.314 ) were all similar between AD and AR. However, medical experience in MOS differed between AD and AR (40% vs. 52% > 5 years p=0.047). Furthermore, 29% of ARs spent at least 25% of their time treating critically injured patients vs 12% of ADs (p<0.001).Conclusions: Relative to ADs, ARs have similar military experience yet significantly greater clinical experience. This differential highlights the need for centers like the ATTD and the expansion of such military-civilian partnerships to maintain proficiency in delivering care to our injured heroes.Abstract ID: 38Pharmacological Ascorbate Alters Mitochondrial Dynamics in Pancreatic CancerIntroduction: Pharmacological ascorbate (P-AscH-) generates H2O2 which is selectively cytotoxic to pancreatic cancer (PDAC) cells compared to normal cells. RAS-RAF-ERK1/2 is a major signaling pathway in cancers carrying Ras mutations including PDAC. Exogenously added H2O2 is known to activate ERK1/2 signaling resulting in increases in intracellular H2O2 levels and toxicity of cancer cells. Recent studies by our group demonstrate sustained increases in mitochondrial oxidative stress 48 h after treatment, while altered mitochondrial dynamics has been shown to play a role in growth and survival in PDAC. We hypothesize that the ERK1/2 signaling pathway can regulate mitochondrial functions resulting in toxicity of P-AscH- treated PDAC cells. Methods: Human PDAC cells and non-tumorigenic human pancreatic ductal epithelial cells (H6c7) were treated with 5-30 pmole/cell (0.75-6 mM) of P-AscH- for 1 h. Phosphorylated ERK (p-ERK) levels in control and treated cells, confocal microscopy and flow cytometry measurements with MitoTracker Green, and cellular bioenergetics using the Seahorse Cell Mito Stress Test were determined 48 h later. Mice with PDAC tumors were treated with P-AsH- (4 g/kg IP) or saline for 5 days.Results: PDAC cell lines and tumor xenografts demonstrated an increase in p-ERK levels 48 h after P-AscH- treatment, but not in H6c7 cells. In PDAC cell lines, mitochondrial components as measured by MitoTracker Green fluorescence and confocal microscopy increased by 4 to 10 fold suggesting an increase in mitochondria number consistent with mitochondrial fission. Additionally, ATP production from both oxidative phosphorylation and glycolysis were increased in PDAC cell lines 48 h after P-AscH- treatment.Conclusions: Taken together these findings suggest that ERK1/2 signaling regulates mitochondrial dynamics and mitochondrial functions in P-AscH- treated PDAC cells resulting in sustained oxidative stress and toxicity. These changes in P-AscH--induced mitochondrial dynamics may selectively target susceptibilities in PDAC. Support: P01 CA217797, T32 CA148062.Abstract ID: 39Advances in perioperative analgesic strategies significantly reduce opioid dispensation without increasing surgical adverse outcomes.Introduction: Opioids are routinely administered for perioperative analgesia; however, opioid associated adverse effects are common. We retrospectively examined whether changes in anesthesia practice over time including increased use of multimodal analgesia (MMA), regional analgesia (RA), implementation of enhanced recovery after surgery (ERAS) protocols as well as reduced use of patient-controlled analgesia (PCA) resulted in a reduction of perioperative opioid dispensing and effected surgical outcomes.Methods: Operating room (OR) and postanesthesia care unit (PACU) data from an automated medication dispensing system (Omnicell) was retrospectively reviewed for quality improvement purposes before and after consecutive implementation of systematic opioid use reduction strategies. Omnicell data logs between 2013 and 2018 were interrogated for the total per patient milligram morphine equivalent (MME) and non-opioid analgesic removal. These data were contextualized with the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database for demographic and clinical characteristics and 30-day post-operative outcomes. VASQIP data, per patient MME and non-opioid analgesic removal in parallel to practice changes were compared.Results: Per patient opioid dispensing decreased significantly and continuously from 101.4 MME to 52.5 MME (48.2%) whereas non-opioid analgesic dispensing and RA significantly increased between 2013 and 2018. Annual patient and surgical complexity as well as observed to expected 30-day morbidity and mortality ratios were similar. The 30-day readmission rates decreased from 15% to 12% and hospital length of stay (LOS) from 7.2 to 5.7 days.Conclusions: Implementation of sequential opioid reduction strategies resulted in a significant decrease in per patient opioid dispensation in the OR and PACU while non-opioid medication dispensing significantly increased. We conclude that systematic opioid reduction strategies can be successfully implemented and that reduced opioid utilization does not lead to worse outcomes but may rather contribute to decreases in 30-day readmission rates and LOS.Abstract ID: 40Early outcomes of trans-carotid artery revascularization and fenestrated endovascular aortic aneurysm repair at VA Boston Medical CenterIntroduction:Veterans requiring complex endovascular surgical procedures may be referred outside the VA in certain areas. Barriers to providing complex endovascular surgery within the VA may include lack of hybrid OR availability, lack of surgeon training, or lack of knowledge of available services by referring providers. We sought to review the initial experience of a single VA with two advanced endovascular procedures: trans-carotid artery revascularization (TCAR) and fenestrated endovascular aortic aneurysm repair (FEVAR).Methods:All patients undergoing TCAR or FEVAR at Boston VA Medical Center from 1/1/2019 to 12/31/2019 were retrospectively reviewed. Patient characteristics, operative details and 30-day major outcome measures were collected for both groups.Results:Seven TCARs and four FEVARs were performed during the study period. TCAR patients averaged 72 years old with comorbidities including CAD(1/7), HF(3/7), CKD(3/7), and COPD(2/7). Indication for surgery was stroke (2/7), TIA (1/7), and asymptomatic severe stenosis (4/7). All seven had high lesions (above C2) and 3 had prior neck surgery. Mean operative time was 122 minutes, and contrast was 13.5 mL. There was one adverse postoperative event (hematoma) and zero perioperative stroke, MI, TIA, or death. FEVAR patients averaged 72 years with CAD(3/4), HF(2/4), CKD(2/4), and COPD(3/4). Mean aneurysm maximum diameter was 5.9cm and infrarenal neck length was 10.3 mm. All FEVARS were done with percutaneous bilateral groin access. Two patients exceeded 3Gy radiation exposure. Mean operative time was 217 minutes, and contrast was 57.5 mL. There were no adverse perioperative events. All patients were discharged to home on POD 1. At 30 days, there were zero branch occlusions and zero endoleaks. Conclusions:Early outcomes suggest TCAR and FEVAR are technically feasible and safe in the VA setting. Increased availability of these procedures within the VA may improve veterans’ access to advanced endovascular surgery. Further study is required to determine long-term outcomes.Abstract ID: 41Do surgical intervention and acute illness impact success of a Veterans Affairs smoking cessation program?Introduction: Tobacco use remains pervasive amongst veterans. Unfortunately, the negative impact on postoperative outcomes may preclude surgeons from offering operative intervention to patients who smoke. As such, a major health event may provide added incentive to quit. We sought to evaluate the impact of acute illness and surgeon involvement on the success of a Veterans Affairs Smoking Cessation Program as compared to primary care wellness initiatives.Methods: We retrospectively reviewed consults to the pharmacy-led Smoking Cessation Program (SCP) at the Middleton Memorial VA Hospital from 2017 to 2019. Consults placed during the last three months were categorized based on the source of referral: primary care, acute care and interventional specialties. Descriptive statistics were used to assess rates of veteran engagement based on referral source. Consult completion was used as a proxy for veteran engagement.Results: A total of 2993 new SCP consults were placed during the study period. Overall, veteran engagement rose from 43% in 2017 to 53% in 2019. In recent months, there were 282 SCP referrals. While only 19 (7%) of these referrals were placed by interventional specialties – primarily cardiology and thoracic surgery – the rate of veteran engagement was 63%. The majority of referrals (65%) were placed by primary care providers with an engagement rate of 68%. In contrast, only 42% of consults placed in the context of an acute illness were completed.Conclusions: In our study, primary care directed smoking cessation referrals were most prevalent and resulted in the highest completion rates. The presence of an acute illness in isolation failed to impact program success. However, while surgeon initiated referrals were meager in quantity the success rate approached that of primary care. This finding suggests that surgeons play a powerful role in influencing patient behavior that may be harnessed to augment success of existing smokingAbstract ID: 42Ascending Thoracic Aortic Aneurysm Growth is Minimal at Sizes that Do Not Meet Criteria for Surgical RepairIntroduction: Historic studies of nonsyndromic ascending thoracic aortic aneurysms (aTAAs) suggested that aTAA growth rate was approximately 0.1cm/year, but data were limited, with relatively few studies using computed tomography (CT) imaging. The purpose of our study was to reevaluate the annual growth rate of nonsyndromic ATAAs that do not meet criteria for surgical repair in the contemporary era.Methods: Patients undergoing ATAA surveillance with repeat imaging taken 3, 4, or 5 years apart were identified and categorized based on imaging type (CT with and without contrast, or magnetic resonance imaging (MRI)) and imaging resolution. Maximum aTAA diameter was analyzed. Average rate of growth was evaluated based on longest available follow-up. Diameters at baseline vs. each subsequent scan at 3, 4, and 5 years were compared using paired t-tests.Results: A total of 114 veteran patients with both baseline and follow-up scans were identified. Of these patients, 61 had baseline and follow-up CT scans with contrast, 9 had baseline and follow-up CT scans without contrast, 1 had baseline and follow-up MRI scans, and 43 had baseline and follow-up scans taken with mixed imaging modalities. The average baseline aTAA diameter was 43.3 mm. There were no significant differences between rate of growth amongst the four groups.55% of patients (n=63) demonstrated no aneurysm growth. The remaining 45% of patients (n=51) demonstrated aTAA growth, at an average rate of 0.7mm/yr. There was also no significant difference between aneurysm diameter at baseline vs. 3 years (p=0.63), 4 years (p=0.81), or 5 years (p=0.73).Conclusions: In this veteran population, the majority of patients did not experience annual aneurysm growth over 5 years, regardless of initial aTAA diameter. Thus, in the modern era, aTAAs may not grow as quickly as previously described, which will be important in determining appropriate intervals for aneurysm surveillance based upon risk:benefit ratio.Abstract ID: 43Determinants of Maximum Voided Volume: Results from the Krimpen StudyIntroductionMaximum voided volume (MVV, formerly known as functional bladder capacity) is an important determinant of daytime and nighttime lower urinary tract symptoms (LUTS) in both men and women. Previous studies have focused on the association between MVV and LUTS such as nocturia, but MVV has not been interpreted in the context of height and weight. Accordingly, we sought to determine the potential relationship between MVV, height, and weight.MethodsPost hoc analysis of voiding diary data obtained from the Krimpen study, a large community-based study of Dutch men aged 50-78 years, was carried out. A total of 1,688 men were included at baseline. MVV, defined as the single largest voided volume recorded on the 24-h voiding diary, was compared to BMI (kg/m2), height (m), and weight (kg) through simple and multiple linear regression analyses. Adjustments were made for International Prostate Symptom Score (IPSS) and age. ResultsSimple linear regression analyses revealed a significant positive correlation between MVV and both height (B = 305.65, p<0.001) and weight (B = 1.33, p = 0.001). Smaller MVV was strongly correlated with higher age (B = -2.66, p<0.001) and self-reported LUTS as determined by the IPSS (B = -5.18, p<0.001). MVV had no association with BMI (B = 1.31, p = 0.348). After adjustment, multiple linear regression analysis demonstrated that height was a stronger physiologic predictor of MVV (B = 232.87, p = 0.002) compared to weight (B = 0.50, p = 0.253).ConclusionsIn the present study, MVV was independently correlated with height but not weight, nor BMI. Height should be considered in the interpretation of MVV values to further individualize the evaluation and management of both daytime and nighttime LUTS. It is postulated that height is a fixed anatomic characteristic likely related to internal organ size while weight fluctuates with variation in diet and caloric expenditure.Abstract ID: 44The Use of Extracorporeal Support to Rescue Patients Who Experience Life Threatening Complications After A Complex General Thoracic SurgeryIntroductionPostoperative acute lung injury and ARDS is associated with high mortality following a general thoracic procedure. Extracorporeal membrane oxygenation (ECMO) offers an alternate means of cardiopulmonary support when conventional methods fail. We report indications, outcomes, and complications in patients who after complex general thoracic surgery developed a postoperative complication requiring ECMO support.MethodsWe retrospectively reviewed all patients who required ECMO support in the post-operative period following a complex general thoracic procedure from January 2003-December 2019. Preoperative and perioperative variables were analyzed. Patients who underwent a cardiac procedure, or cardiothoracic transplantation were excluded. ResultsA total of 51 incidence of ECMO were utilized in the postoperative setting in 49 patients who underwent a surgery with the thoracic surgical service (VV ECMO 88.2%(n=45), VA ECMO 11.8% (n=6)). Majority of index operations were esophageal (45.1%) followed by lung resection (29.4%), and airway reconstruction (7.8%). Median time to ECMO initiation from the index operation was 2.4 months (1 day to 43 months). Median length of ECMO support was 7.6 days (range 5 hours to 31 days). Majority of patients were cannulated in an urgent (64.7%) or emergent (29.4%) fashion. Additional operations on ECMO support were performed in 80.4%(41) patients with the most common procedures being esophageal bipolar exclusion (19), airway repair (17), and completion pneumonectomy (9). ECMO related complications included bleeding (9) and cannula related limb ischemia(2). 30-day survival was 57.1% (28/49) and 51% (25/49) of patients discharged home. Of the patients with adequate follow-up of 90 days, 70.8% of patients who were discharged were still alive.ConclusionECMO provides a safe and viable alternative to cardiopulmonary support in patients who experience severe postoperative complications following complex general thoracic surgery. The results of this study suggest the use of ECMO can offer a survival advantage in patients presenting with catastrophic postoperative complications.Abstract ID: 45Cognitive Load Measurement to Assess Resident Skill Acquisition During a Sub-specialty Rotation: A Pilot StudyIntroductionSurgical sub-specialties represent board-tested content areas, yet general surgery residents often have little clinical exposure to these fields. The limited exposure to content and procedures within sub-specialties creates excess cognitive burden which may impede skill and knowledge acquisition. We sought to utilize procedure-specific cognitive load measures to identify barriers to board exam preparedness and procedural competency for general surgery residents.MethodsSecond year surgical residents on a thoracic surgery rotation were surveyed to determine pre- and post-rotation preparedness. The NASA-TLX (National Aeronautics and Space Administration Task Load Index) survey, a validated instrument to measure cognitive load, was administered following each of three selected case types: bronchoscopy, esophagogastroduodenoscopy (EGD), and video-assisted thoracoscopic surgery (VATS). Residents received immediate post-procedure feedback and standardized debriefing following each case. ResultsMean total NASA-TLX scores were highest (indicating greater cognitive load) for EGD and VATS (p=0.001). When comparing sub-scale measures, “Mental Demand” was significantly higher for VATS (p=0.0256) compared to the other procedures whereas “Physical Demand” was highest for EGD (p=0.018). Self-reported “Frustration” was similar for all case types (p=0.247). Cognitive burden decreased with a greater number of procedures. Significant improvement was noted at the end of the rotation in self-assessed procedural competency and preparedness for thoracic board topics (all p<0.05). Post-procedure debriefing and feedback by the attending surgeon increased resident self-reflection and completion of procedural self-evaluations. ConclusionsLongitudinal assessment of procedure-specific cognitive load in combination with standardized post-procedural debriefing reveals intervenable barriers to procedure and skill acquisition. Targeted curriculum development tailored to the individual procedures utilizing the NASA-TLX assessment to gauge efficacy represents a step towards ensuring competency, particularly in fields with minimal clinical exposure. A key to successful implementation of such a program is immediate standardized feedback by attending surgeons.Abstract ID: 46Implementation of a Dedicated Surgical Oncology Clinic within VA - Tennessee Valley Healthcare System (VA-TVHS)Introduction:While many Veterans Affairs (VA) medical centers provide Surgical Oncology care within General Surgery clinics, such clinics pose challenges to timely cancer care due to high levels of trainee turnover and lack of specialty-trained supervision. We sought to improve the quality of surgical cancer care provided within a resident-run clinic through a multidisciplinary quality improvement project. Methods:We implemented a bundled intervention (creating dedicated Surgical Oncology block time within the VA General Surgery clinic, designating a specialty-trained surgeon to attend the clinic, creating a structured pre-visit review form to facilitate advanced review and determine the need for additional studies, and formulating clinical algorithms for the most common cancers to serve as a checklist for NCCN-concordant care and surveillance) in one VA facility and evaluated its impact using a pre-post analysis. The primary quality outcome was mean time from evaluation to resection, as determined through the electronic health record. Results:The intervention was implemented in September 2019, with 57 patients evaluated pre-intervention and 57 post. Patients’ mean age was 66 (range 44 – 90) and the most common presenting neoplasm was colorectal (17.5%). After initiation of the clinic, the mean time from surgical consultation to operation decreased from 23.8 days to 13.9 days (P=0.015). We also measured overall surgical volume and referral for care in the community, as these factors could impact timeliness of resection. The percentage of patients scheduled for operation from clinic did not significantly change over the time period (61.4% pre- versus 65.1% post-intervention, P=0.90), nor did rates of referral for surgical care outside the VA (3.9% pre- versus 5.0% post-intervention, P=0.77).Conclusions:A multidisciplinary quality improvement project improved timeliness of surgical cancer care provided to Veterans. Future work includes additional efficiencies and reductions in time to resection and determining the impact upon patient and trainee satisfaction.Abstract ID: 47Nudging patients and surgeons toward optimal ambulatory post-operative pain management: results of an opioid buyback program at a VHA Surgical Level-2 FacilityIntroduction: Following ambulatory surgery, patients manage post-operative pain at home, often with opioids. Optimal opioid stewardship would provide patients with enough medication to control intense discomfort and avoid diversion of unused prescription opioids. This Veterans Health Administration (VHA) funded pilot program was designed to see if small monetary reimbursements would motivate patients to return unused prescription opioids after ambulatory surgery. An additional goal was to determine whether feedback from this buyback program would alter surgeon prescribing.Methods: using ambulatory Current Procedures Terminology (CPT) codes historically associated with opioid prescribing at our facility, we identified opioid-na?ve patients at a VHA Surgical Level-2 Facility from April 2017-August 2019 across all surgical services. We reimbursed $5/unused opioid pill ($50 limit) returned for proper disposal through the program. We tracked the number of participants, number of unused opioids returned, surgeon prescribing (in morphine equivalents, M.E.) and refill requests.Results: Of 1663 patients who met inclusion criteria, 883 received opioid prescriptions: 258 (29.8%) returned unused opioids (2932.5 pills). With feedback to prescribing surgeons, trends in prescribing included a decrease in the number of patients receiving opioid prescriptions: 62.6% (2017) to 48.7% (2018) [p Conclusions: An opioid buyback decreased the number of opioids available for diversion in communities and feedback on returns allowed surgeons to calibrate their prescribing patterns, without an increase in the number of patients seeking refills. These observations suggest that small monetary nudges may have an outsized influence on optimizing opioid prescription and usage, and proper disposal within the VHA.Abstract ID: 48Surgical resection for endoscopically unresectable polyps in a single-center VA Cohort: Is it worth the risk?Introduction:While large bowel polyps that are too large for endoscopic removal may require bowel resection, there are risks associated with operative removal. This is especially true among patients within the Veterans Health Administration (VA), who are often older with more comorbid conditions. Methods:We performed a retrospective review of Veterans who underwent colorectal resection for endoscopically unresectable polyps between 2010 and 2015 within a single, tertiary VA medical center. Patients were included if the biopsy resulting from endoscopy identified an adenomatous polyp without invasive cancer. Results:There were 110 patients identified in the cohort. The median age was 64 (range 45 to 83), and patients were predominantly male (94%) and White, non-Hispanic (85%). The median number of attempts at endoscopic retrieval prior to surgical resection was 1 (range 1 to 5). Invasive cancer was identified in 20 patients (18.2%), including 5 (4.5%) with node-positive disease. Biopsy histology demonstrated high-grade dysplasia among 11 patients (55%) with invasive cancer and 2 patients (40%) with node-positive disease. Among those with invasive cancer, biopsy demonstrated 7 tubular adenomas (35%) and 13 tubulovillous or villous adenomas (65%). Within 30 days of resection, 3 patients (2.7%) died, 4 (3.6%) required reoperation, and 11 (10%) were readmitted. During long term follow-up, 22 patients (20%) died, with median time to death 2.8 years. By multivariable logistic regression, biopsies demonstrating dysplasia were more likely to harbor malignancy (OR 3.15, 95% confidence interval 1.2 – 8.6). Neither histologic type (tubulovillous or villous versus tubular adenoma) (P=0.97) nor polyp location (P=0.84) were significantly associated with risk of invasive cancer. Conclusions:Given the risks associated with a major abdominal operation in a population of elderly Veterans, the decision to proceed with surgical resection of an endoscopically unresectable polyp should be a multidisciplinary discussion which considers the overall clinical status of the Veteran.Abstract ID: 49Risk Factors for Wound Complications after Lower Extremity Amputation: Analysis of VASQIPINTRODUCTION: Lower extremity amputations (LEA) for chronic limb ischemia are plagued by wound complications due to inherent patient factors that necessitated the amputation. We have analyzed the Veteran Affairs Surgical Quality Improvement Program (VASQIP) in effort to identify risk factors for wound complications after LEA. METHODS: After obtaining IRB approval, VASQIP data was obtained through the Data Access Request Tracker (DART) application for fiscal year 1999 to 2018. CPT codes for above and below knee amputations (AKA, BKA) were used to identify patients. Pre-operative comorbidities and peri-operative variables were extracted from this database. Wound complications were defined as wound disruption/dehiscence or surgical site infection (SSI). Data was analyzed with univariate analysis and forward stepwise logistic regression in SPSS (v25, IBM) to determine the risk factors for wound complications. RESULTS: There was a total of 50,083 unique patients identified. 98.8% of patients were male with an average age of 66 ± 10. There were 28,768 BKAs and 21,315 AKAs. The rate of post-operative wound complication was 6.4% (n=3,201). When risk adjusted, wound complications were higher in patients with COPD (OR 1.22, 95% CI 1.11-1.31, p<0.001 ), chronic steroid use (OR 1.26, 95% CI 1.02-1.55, p=0.032), non-independent functional status (OR 1.16, 1.03-1.30, p<0.001), smoking within the last year (OR 1.25, 95% CI 1.14-1.37, p<0.001), longer operative times (OR 1.13, 95% CI 1.09-1.19, p<0.001), BKA (OR 1.38, 95% CI 1.26-1.50, p <0.001), and general surgeons performing the amputation (OR 1.20 , 95% CI 1.10-1.31, p<0.001). CONCLUSION: Wound complications after major LEA continues to be commonplace. Risk factors for wound complications include COPD, chronic steroid use, non-independent functional status, smoking within the last year, BKA, and general surgeons performing the surgery. These findings highlight the need to consider the patient’s preoperative comorbidities to determine their ability heal the amputation prior to surgery.Abstract ID: 50The Impact of Different Types of Pain Management Modalities on Post-operative Delirium.Introduction:Delirium is a common problem in patients undergoing surgery. Evidence suggests that the type of anesthesia used, and post-operative pain management approach can impact the frequency of delirium but there is no consensus on this issue. This study explored the role of peri-operative nerve block in managing postoperative pain and its association with the development of delirium.Methods:A total of 440 patients who underwent lower limb amputations and hip and knee arthroplasties between January 2010 and December 2017 were reviewed. We evaluated the different pain management strategies used (especially post-operative nerve blocks) to see what effect they had on the frequency of delirium development. Thirty different variables were assessed. The Cramer’s V statistical method was used to determine possible associations with delirium. Results:A total of 60 patients (13.6%) from the 440 studied developed post-operative delirium. For each yearly increase in age, the odds of delirium increased by 1.05 and the odds further increased by 4.60 in patients with a prior diagnosis of dementia. Even after controlling for the anesthesia type (general, local, regional, spinal and epidural), no association between nerve block and delirium was observed (P=0.41). Among the different pain management strategies (IV Tylenol, gabapentin, oral narcotics, patient-controlled analgesia, and NSAIDs), only gabapentin was associated with delirium, demonstrating a 2.27 times higher risk (P=0.0085). We also found that prior narcotic use increased the odds of delirium (P=0.0053). Conclusions:We found that taking gabapentin post-operatively for pain management, as well as having a history of ongoing narcotic usage prior to surgery, were associated with a higher risk of developing delirium. In addition, increasing age and patients with prior dementia were at a higher risk of delirium in the post-operative period. We found no association between nerve block used and the development of delirium.Abstract ID: 51Pre-operative Advance Care Planning in Patients with Malignancies Undergoing General AnesthesiaAdvance care planning (ACP) involves documenting patients’ health care wishes, surrogate information and preferences regarding life sustaining treatments using Advance Directives (AD). Prior research indicates that less than 20% of hospitalized veterans have AD. The VHA has a new nation-wide initiative prioritizing ACP for patients, called ‘Life Sustaining Treatment Decisions Initiative’ (LSTDI). It enables a ‘Life Sustaining Treatment’ (LST) note reflecting Goals of Care Conversations (GoCC) to be entered into a standardized location in the computerized patient record system (CPRS). A retrospective chart review was performed over a period of 5 months to determine how many patients with malignancies had ACP documented in CPRS prior to date of surgery. A total of 78 such patients underwent procedures under general anesthesia in General Surgery (GS), Urology and Otolaryngology (ENT) divisions. Average patient age was 68 years. Prior to LSTDI implementation, 4/6 (67%) GS, 2/3 (67%) ENT and 2/15 (13%) Urology patients had an AD prior to surgery. During the 10th and 11th months following LSTDI implementation, 16/23 (70%) GS, 8/17 (47%) Urology and 0/6 (0%) ENT patients had either AD or LST note prior to surgery. Sixteen months following implementation of LSTDI, there was no discernable improvement in use of ACP prior to surgery: 2/3 (67%) ENT, 0/2 GS (0%) and 1/3 (33%) Urology patients had either AD or LST notes completed prior to surgery.Anesthesia and surgery may render patients at higher risk for cardiopulmonary arrest. Prior to undergoing surgery, it is important to clarify patients’ wishes regarding life sustaining treatments and to document them using ACP. Although ACP tools exist within CPRS, they are currently not prioritized by clinicians. Implementation of LSTDI aims to encourage a culture change whereby ACP is prioritized for high risk patients. This can help ensure provision of goal concordant care in the peri-operative setting.Abstract ID: 52Anesthesiology Pre-operative Consultation for Patients Undergoing Eye SurgeryCancellation of scheduled surgical cases adversely affects delivery of care, patient satisfaction, and operating room efficiency and utilization. Ambulatory ocular surgery accounts for approximately 20% of the surgical case volume at the Baltimore VA Medical Center. Of the 214 ocular cases scheduled during the 2nd quarter of FY2019, twenty-one (10%) were cancelled. A pilot performance improvement project was conducted. Data was collected and analyzed at the end of the project. During the 3rd quarter of FY2019 an anesthesiologist was embedded into an established nurse-led preoperative assessment center. 86 out of 197 scheduled patients were evaluated by the anesthesiologist during this time period. A pre-anesthesia evaluation note was completed in CPRS. Scheduling issues prevented the anesthesiologists from evaluating all scheduled patients.The overall cancellation rate for ambulatory ocular surgery cases during 3rd quarter FY2019 was decreased as compared to 2nd quarter FY2019 (7% vs 10%). The avoidable cancellation rate, as recorded in VistA, also decreased (3% vs 7%). The avoidable cancellation rate was 43%. Of the cancelled cases, 36% were evaluated preoperatively by an anesthesiologist. This project resulted in a decreased rate for the overall case cancellation for ocular surgery cases during the 3rd quarter FY2019 by 30%. Furthermore, it decreased the avoidable cancellation rate by approximately 60%. Involvement of an anesthesiologist during a nurse-led preoperative assessment process as demonstrated by the above parameters, showed a significant improvement in the delivery of care for ambulatory ocular surgery patients.Abstract ID: 53Creation and Implementation of an Enhanced Recovery after Surgery (ERAS) Pathway for Colorectal Surgery at a VA HospitalIntroduction: Enhanced recovery after surgery (ERAS) pathways have been demonstrated to reduce length of stay (LOS) and complications after colorectal surgery. Implementation can be widely variable and limited data regarding ERAS utilization is available in the Veterans Affairs (VA) health system. Our objective is to describe the development and implementation of a multidisciplinary ERAS pathway for colorectal surgery at a Level 1a VA medical center, to provide a framework that may assist other VA hospitals in implementing local ERAS protocols. Methods: Although some ERAS components were started earlier, such as addition of alvimopan to the hospital formulary in 2016, formal pathway design began in August 2018 and was implemented in April 2019. Our process involved multidisciplinary input from representatives involved in all stages of patient care, including surgeons, anesthesiologists, nurses, dieticians, physical/occupational therapists, and social workers. Results: Our protocol consists of pre-, intra-, and postoperative components, adhering to ERAS guidelines distributed in the July 2018 memorandum from the National Surgery Office. Multimodal analgesia begins intraoperatively and includes standard use of ketorolac. Unless contraindicated, all patients receive alvimopan. Postoperatively, emphasis is placed on early ambulation, diet advancement with provision of high-protein supplements (also provided preoperatively), and addressing discharge barriers. In a comparison of VASQIP data for colectomy pre- (2016) and post-ERAS (2019), we observed improvements in both mean LOS (from 9.0 to 6.3 days locally, versus 9.2 to 7.9 days nationally) and 30-day readmission rates (18.8% to 3.8% locally, versus 12.4% to 13.3% nationally). Conclusions: We successfully developed and implemented a multidisciplinary evidence-based ERAS pathway for patients undergoing colorectal surgery, with subsequent improvement in LOS and readmission rates. Challenges included the substantial time required to gather multidisciplinary input, create new media (patient education booklets and order sets), and provide education to all stakeholders regarding implementation of the new system.Abstract ID: 54Manuscript Publication of Abstract Presentations at the Association of VA Surgeons Meetings: a multiyear analysisBackground:Presentation of scientific work at national meetings is a rite of passage for surgical residents and academic surgeons. The proportion of presented works that is ultimately published in peer reviewed journals is unknown. The aim of this study was to examine the proportion of abstracts presented at the Association of Veterans Affairs Surgeons (AVAS) annual meeting that are ultimately published as peer-reviewed manuscripts along with factors associated with successful publication.Methods:We reviewed all abstracts presented at the AVAS Annual Meeting from 2014 and 2015. We utilized Google Scholar and PubMed databases to determine publication status. We used the names of the first and last author in addition to all or part of the abstract title to search for manuscripts. Descriptive statistics and multivariate logistic regression were employed.Results: We identified a total of 203 abstracts (91 in 2014 [38 full oral and 53 quick-shot] and 112 in 2015 [45 full oral and 67 quick-shot]). Abstract categories included basic science (n=14, 85% published), clinical outcomes (n=184, 45% published), education (n=4, 100% published), and others (n=1). Overall, 49% of presentations were published, including 70% (58/83) of full oral presentations vs 35% (42/120) of quick shot presentations (p Quick-shot presentation (OR=0.28; 95%CI: 0.15-0.53) and clinical-outcome (OR=0.23; 95%CI: 0.03-0.93) were less likely to be published. Conclusion:A substantial amount of scientific work presented at AVAS did not result in manuscript. Future work will investigate barriers to publication of presentationsAbstract ID: 55Frailty Metrics are Associated with Kidney Transplant Denial for Purely Psychosocial ReasonsIntroduction: Frailty metrics are used to screen patients for kidney transplant. However, it is not clear if frailty is associated with patients who are denied for purely psychosocial reasons.Methods: Demographics, frailty metrics, treadmill ability (METS), troponin, and BNP were collected on 373 consecutive veteran patients evaluated for kidney transplant between July 2015 and December 2018 and tested for correlation with listing outcome. Frailty metrics included handgrip, chair sit/stand, 8 foot up-and-go, sit/reach, and questions related to fatigue. Comparison was done between groups accepted and deferred for listing, those denied for medical or functional reasons, and those denied only for psychosocial reasons. Results: Among all patients, 50.1% had a psychiatric diagnosis and 76.5% had any combination of psychiatric, noncompliance, substance abuse, or abnormal cognition history (MOCA≤26). 278 (75%) patients were listed or deferred and 95(25%) denied. Forty-nine were denied with only medical reasons, 22 with medical and psychosocial reasons, and 24 were denied for purely psychosocial reasons. Patients denied for psychosocial reasons were more likely to be non-white (p=0.059), younger (57.3 vs 64.4, p=0.001), and have higher troponin (0.06 v. 0.03, p<.01) than those listed or denied for medical reasons. Medical denials were more likely to be smokers with higher BMI (p≤0.01) . Both medical and psychosocial denial groups had more diabetics than list/defer patients (p≤0.002). Poor functional metrics were more predictive of medical than psychosocial denials, but treadmill (p=0.001), grip strength (p=0.01), troponin (p=0.0004), sit/reach (p<0.0001) and questions about fatigue (p<0.0001) were associated with denial for psychosocial reasons.Conclusion: Functional metrics were associated with kidney listing denial for purely psychosocial reasons despite this group being a younger population with less smoking. This indicates potentially complex interactions between psychosocial factors and physical frailty.Abstract ID: 56Insulin-Dependent Diabetes Mellitus in The Regroup TrialBackground: Insulin-dependent diabetes mellitus (IDDM) patients are more susceptible to complications after coronary artery bypass grafting (CABG) than non-diabetics. The Randomized Endovein Graft Prospective (REGROUP) trial revealed a nonsignificant clinical advantage of endoscopic vein harvest (EVH) over open vein harvest (OVH). The purpose of this sub-analysis is to explore the impact of EVH approach on outcomes among IDDM patients who represent a higher risk population. Methods: IDDM patients from the REGROUP Trial were grouped according to vein harvest technique: OVH vs. EVH. Patient characteristics included age and hemoglobin A1c (HbA1c). The two groups were compared with respect to one-year major adverse cardiac events (MACE), comprised of all-cause mortality, non-fatal myocardial infarction (MI), revascularization and hospital 30-day readmissions. Results: Of the 1150 patients in REGROUP, diabetes mellitus was present in 577 patients (50.2%). Insulin-dependent diabetes present in 262 (22.8%) of which 137 patients were randomized to OVH and 125 to EVH. The two groups were comparable for age (66.4 ± 6.7 OVH vs. 66.7 ± 6.2 EVH) and HbA1c (7.9 ± 1.2 OVH vs. 8.1 ± 1.3 EVH). MACE rates were noted to be higher among OVH patients (22/137, 16.1%) compared to EVH (15/125, 12%) although not significant (p=0.35). Similarly, OVH patients showed consistently higher, albeit nonsignificant, complication rates compared to EVH with regard to death (10.9% vs. 7.2%, p=0.293), non-fatal MI (7.3% vs. 4.0%; p=0.25) and repeat revascularization (4.4% vs. 3.2%, p=0.75). Hospital readmission rates for the two groups were essentially equivalent: 24.8% (34/137) for OVH patients and 25.6% (32/125) for EVH patients (p=0.89).Conclusion: Similar to the findings of the REGROUP Trial, EVH offers a slightly improved clinical outcomes over OVH among IDDM patients undergoing CABG. Although differences were not significant, EVH should be the preferred vein harvest approach in this subgroup whenever possible.Abstract ID: 57The 10-Year Cost Effectiveness of a Regional Veterans Affairs Abdominal Aortic Aneurysm Screening ProgramIntroduction:: Abdominal aortic aneurysm (AAA) screening has demonstrated to be cost-effective in reducing AAA-related mortality. However, a long-term cost analysis of an AAA screening program in a Veterans Affairs (VA) setting has not been studied. This study reports the cost analysis of implementing and sustaining a regional VA AAA screening program.Methods:: An analysis of associated cost data for a regional AAA screening program was conducted from 2007 to 2016, adjusting for inflation to 2019 U.S. dollars, utilizing a $50,000/year intent-to-treat threshold. An intent-to-treat model tracked costs from a patient’s initial screening (≥5.0 cm) to possible AAA repair. A Decision Support System software was used to obtain direct and indirect encounter costs from Medicare billing codes associated with screening and AAA repair, including pre-op and post-op costs. Open versus Endovascular Repair (OVER) Trial AAA repair costs were used and converted to 2019 dollars. Only AAA repairs done at VA were used to calculate overall costs. All data were collected as of 12/31/2019. Results: A total of 19,649 patients were screened for AAA with 119 patients screened AAA ≥ 5.0 cm. The total estimated cost of AAA screening was $2,742,607 ($140/screening). There were and 86 of these patients required repair (58 repairs at VA). The average cost of elective endovascular repair (n=50) was $41,886.84 and open repair (n=8) was $48,556.10, for a total cost of $2,482,790.80. The total 10-year cost of the AAA screening program (screenings + repairs) was $5,225,397.80. To save 1 life with AAA repair required 229 screenings at an average cost of $32,060).Conclusions: Implementation of a AAA screening program to manage 19,649 patients was $5.2 million. The program is less than the $50,000/year intent-to-treat threshold. Future studies will evaluate cost data for patients who underwent care outside of the VA.Abstract ID: 58Implementation of Enhanced Recovery After Surgery (ERAS) pathway in patients undergoing radical cystectomy in a large VA medical center: immediate impact of surgical outcomesIntroduction:Enhanced recovery after surgery (ERAS) protocols are associated with better postoperative recovery in patients undergoing open radical cystectomy (RC). However, there is a paucity of literature examining the impact of ERAS in Veterans, who have a unique set of risk factors. We sought to examine the influence of an ERAS protocol in patients undergoing RC at a large Veterans hospital in the mid-Atlantic region.Methods:This was an IRB-approved retrospective study of all patients undergoing elective open RC at McGuire VAMC between 1/1/2018 and 12/1/2019. Patients who underwent RC prior to 12/15/2018 were treated as historical controls and compared to those undergoing RC after implementation of a standardized ERAS protocol. Length of stay (LOS) and pain control were analyzed for both cohorts.Pre-operative components of the protocol included: patient education, avoidance of bowel preparation, and consumption of clear carbohydrate drinks until two hours prior to surgery. Intraoperative measures included: standardized anesthetic management, goal directed fluid therapy, minimizing the use of opiates, and favoring thoracic epidural analgesia. Post-operative components included: avoidance of nasogastric tubes and nothing by mouth status, adoption of multimodal pain control, early ambulation and early removal of drains. Results: A total of twenty-three patients were evaluated. Eleven completed the ERAS pathway vs 12 controls. Charlson Comorbidity Index, estimated blood loss, age and sex were similar in both cohorts. A statistically significant decrease in intraoperative, perioperative, and postoperative opioid use, as measured by morphine equivalents, was appreciated (p=0.02, p=0.04, p=0.02, respectively). Additionally, a clinically significant reduction in LOS was found by our ERAS group (6.5 vs 9.1 days; p=0.058). Conclusion:The implementation of an ERAS pathway for Veteran patients undergoing open RC translates into decreased perioperative narcotic use and LOS. These findings corroborate previous literature and support the use of ERAS pathways in the Veteran population.Abstract ID: 59Experienced bedside-assistants improve operative outcomes for surgeons early in their learning curve for robot assisted radical prostatectomyRobot assisted laparoscopic radical prostatectomy (RALRP) is a complex robotic procedure for both the surgeon and beside assistant (BA). The use of an experienced BA may be helpful for surgeons at the beginning of their learning curve.We sought to determine if an experienced bedside assistant could improve outcomes for surgeons early in their learning curve for RALRP.Methods:A retrospective cohort study of a single surgeon’s cases during the first 3 years of practice (2013-2015) was performed Patient demographic, peri-operative and oncologic data were collected and analyzed. Experienced beside assistant were defined as any assistant who had undergone dedicated training as a bedside assistant either through the UTSW physician assistant residency or a comparable outside training program. Urology residents were not considered expert assistants. Univariate and multivariate analyses were performed to determine if expert BA was a predictor of post-operative outcomes.Results:In total, 170 cases were performed, of which 111 (65%) were performed without an expert BA and 59 (35%) were performed with an expert BA. Groups were not significantly different with regards to patient demographics (p>0.05 for all). On univariate analysis, having an expert BA was associated with a significantly lower LOS (31 hr±21 vs. 42hr±26, p=0.004), EBL (296ml ±180 vs. 441ml ±305, p<0.0001) and positive margin rate (20% vs. 37%, p=0.03). On multivariate analysis, expert BA remained a predictor of decreased LOS (B stat= -8.4, 95% CI -16.0, -1.2, p=0.02), EBL (B stat= -138, 95% CI -225, -51, p=0.002) and decreased positive margin rate (OR-2.8, 95% CI -6.6, -1.2, p=0.02).Conclusions:Our results demonstrate that the use of an expert BA may correlate to improved patient outcomes early in the learning curve of RALP, namely, positive margin rates, estimated blood loss and hospital length of stay. Further studies are needed to confirm these results.Abstract ID: 60Differential Variation in Clinical Characteristics and Outcomes by Race Among Women Versus Men Undergoing Laparoscopic Roux-en-Y Gastric Bypass (LRYGB)Introduction: The clinical characteristics and outcomes for patients undergoing Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) vary by race. Whether or not race variation patterns differ by sex is unknown. We will identify differential patterns of clinical variation by race pre- and post-LRYGB among women compared with men.Methods: Data (weight, BMI and 31 co-morbidities) from 83,059 BOLD LRYGB patients was analyzed retrospectively by self-reported race (Black, Caucasian, Hispanic, Other(Native American, Pacific Islander, and two others) in two separate groups: Women (n=65,325) and Men (n=17,734). Outcomes analysis used general Linear Models including baseline and post-operative data and were modified for binomial distribution of dichotomous variables.Results: Female and male pre-LRYGB weight, BMI, age, employment, and health insurance varied by race. BMI and weight varied through 24 months. Female obesity, hernia, panniculitis, cholelithiasis, GERD, liver disease, stress incontinence(SUI), CHF, hypertension, obesity hypoventilation syndrome (OHS), asthma, sleep apnea, pulmonary hypertension (PHT), dyslipidemia, diabetes, gout, angina, ischemic heart disease, DVT/PT, leg edema, fibromyalgia, depression, mental health diagnosis(MHD), psychological impairment, back pain, musculoskeletal pain, impaired function(IFS), pseudotumor cerebri, alcohol/tobacco/substance abuse (N=30) varied by race (p < 0 .05). Men varied by race in 28 co-morbidities, differing from women in peripheral vascular disease variation (p < 0 .01) and in asthma, OHS, SUI, and tobacco variation. Female/male baseline race variation patterns differed in 11 categories. Twenty-three 12-month co-morbidities varied by race in both sexes; inter-sex differentiation in 5. At 24 months, female cholelithiasis, SUI, diabetes, hypertension, PHT, MHD, depression, psychological impairment, IFS, and substance abuse varied, but only male depression, dyslipidemia, and psychological impairment. Conclusions: LRYGB women and men vary by race in different patterns, from pre-operative baseline through 24 months. The advance knowledge of persistent 24-month female race variation in diabetes, hypertension, and PHT may stimulate increased index of suspicion for these dangerous co-morbidities, resulting in presumptive targeted management and possibly improvedAbstract ID: 61Safety profile of HMG-CoA Reductase Inhibitors in the Role of Burn Wound Injury ConversionIntroductionPrevention of burn conversion from partial to full-thickness would decrease need for surgical excision, hospital length of stay and complication rates. HMG-CoA Reductase Inhibitors (statins), have been proposed to reduce this inflammatory response. We propose that atorvastatin will prevent burn wound conversion and aim to evaluate its safety in this application.MethodsWe performed a retrospective chart review of patients admitted to Roger Seibel Burn Treatment Center in Buffalo, New York who received atorvastatin during their hospital stay from May of 2016 to May of 2019. We analyzed demographics, total body surface area of burn injury (TBSA), drug doses administered, creatinine phosphokinase levels (CK), aspartate aminotransferase (AST) levels, mortality and adverse events.Results49 burn patients were identified who received atorvastatin during admission. TBSA ranged from 1-90%, atorvastatin dosages ranged from 10-80 mg. Nine patients had either CK > 500 or AST > 100 at some time during their hospital stay. No correlation of the elevations with timing of drug administration was found and all subsequently normalized. No adverse events that could be associated with atorvastatin were identified.There were 7 mortalities (14.3%) which exceeded our expected mortality rate of 2.7%. Upon review, 6 of 7 mortalities included patients who chose comfort measures treatment due to severe injuries and/or poor pre-injury quality of life.ConclusionsAtorvastatin used in the treatment of patients with burn injuries was not associated with any adverse events or attributable lab abnormalities. While a higher than expected mortality was observed in our patient cohort, this is likely a result of patients’ prehospital regimen due to preexisting medical conditions or addition by our providers due to their increased severity of injury. We believe that atorvastatin is safe for further randomized prospective study to determine the drug’s effect on prevention of burn wound conversion.Abstract ID: 62Surgical Management of Sarcomatoid Carcinoma of the LungIntroduction: Pulmonary sarcomatoid carcinoma is a rare malignancy. The impact of this histology on survival and recurrence remains poorly defined. The purpose of this study is to evaluate the oncological outcomes for pulmonary sarcomatoid carcinoma. Methods: We retrospectively reviewed all patients who underwent surgical resection for pulmonary sarcomatoid carcinoma between January 2003 and December 2017. Using the IASLC 8th Edition for lung cancer staging, we compared patient and tumor characteristics, survival and recurrence rates stratified by stage. The primary endpoints were recurrence free and overall survival. We also evaluated the relative impact of other adverse prognostic factors between the stages, such as lymph node status, visceral pleural invasion (VPI), angiolymphatic invasion (ALI) and tumor-infiltrating lymphocytes (TILS). Results: 104 patients were identified (mean age 67.3±9.4 years) with 56 males (53.3%) and 48 females (45.7%). Average pathologic tumor size was 4.4±2.3cm (range 0.8-25). There were 27 (26.0%) Stage 1, 39 (37.5%) Stage 2, 29 (27.9%) Stage 3 and 9 (8.7%) Stage 4 patients. 37 patients (35.6%) were upstaged on final pathology because of size (38.6% of upstaged patients), nodal involvement (41.7%), metastases (2.8%), or both size and nodal involvement (16.7%). There was no significant difference in VPI and TILS between the stages. ALI was significantly higher in non-Stage 1 tumors (81.8 vs 59.3%, p=0.018). At mean follow-up (31.2 months), 45.2% of patients recurred (19.0% locoregional, 81.4% distant). 5-year recurrence free and overall survival for all patients were 48% and 52%, respectively. Survival rates of 55% for resected Stage 1 tumors is lower than expected compared to conventional non-small cell lung cancer.Conclusion: Our data shows that primary pulmonary sarcomatoid carcinoma is associated with worse recurrence free survival in clinical Stage I disease. Poorer prognosis may be associated with an upstaging effect and the presence of increased proportion of tumors with ALI.Abstract ID: 63Durability and Structural Valve Degeneration of Transcatheter Aortic Valve ReplacementTranscatheter aortic valve replacement (TAVR) has become the predominant treatment for patients with severe aortic stenosis of any surgical risk. However, TAVR durability is unknown, impacting low-risk younger patients. Limited mid-term TAVR is available. Our objective was to evaluate short and mid-term TAVR outcomes at our Veteran Affairs Medical Center. TAVR patients from November 2013 to May 2019 were retrospectively analyzed. Standardized criteria were used from the European Association of Percutaneous Cardiovascular Interventions and Valve Academic Research Consortium-2 consensus statements. 250 patients (age 80.5±8.7 years) underwent TAVR with 76 self-expanding, and 174 balloon-expandable devices implanted. Overall device success was 98.8%.Survival at 30 days was 98.8%, 1 year was 89.4%, 3 years was 72.0%, and 5 years was 58.7%. Short-term 30-day procedural outcomes included (n,%): bleeding (12,4.8%), cerebrovascular accident (8,3.2%), vascular injury (6,2.4%), cardiac tamponade (3,1.2%),and acute kidney injury (1,0.4%). Mid-term outcomes included (n,%): permanent pacemaker (42,16.8%), SVD (12,4.8%), thromboembolism (12,4.8%), bioprosthetic valve failure (3,1.2%), and endocarditis (2, 0.8%).TAVR SVD was categorized by: moderate hemodynamic SVD (10,4.0%), severe hemodynamic SVD (1,0.4%), or morphological SVD with leaflet integrity abnormality (1,0.4%). Patients with SVD consistently had mean transprosthetic gradients >20mmHg, with the exception of 1 patient who spontaneously resolved to normal gradients. One patient underwent aortic reintervention, and 1 patient underwent paravalvular leak repair.GROUP 3Abstract ID: 64An ACS NSQIP Analysis of Surgical Outcomes for Intraductal Papillary Mucinous Neoplasms of the PancreasIntroduction: Intraductal papillary mucinous neoplasm (IPMN) incidence is increasing and its status as a pancreatic cancer precursor often complicates management. Guidelines for recommending pancreatectomy are evolving and emphasize resection in cases with invasive disease or high-grade dysplasia (IPMN-I) and forgoing surgery in non-invasive disease (IPMN-NI). We identified national trends in IPMN management and examined outcomes following pancreatectomy for IPMN versus non-IPMN indications. Methods: The ACS NSQIP general and targeted pancreatectomy datasets were merged to identify subjects undergoing pancreatic surgery from 2014-2018. IPMN-I to IPMN-NI incidence was examined longitudinally using database-defined pathologic categories. These were aggregated as an ‘IPMN’ cohort for comparison to all other cases as a ‘Non-IPMN’ cohort. Outcomes were evaluated with chi-squared tests and Poisson regression. The primary outcome measures were clinically-relevant pancreatic fistula (CR-PF) incidence and overall major morbidity. Secondary outcomes included 30-day operative mortality and length of stay (LOS). Results: 31,965 subjects were identified; the annual incidence of pancreatectomy increased from 4,702 to 6,547 over the study period. 3,112 (9.7%) cases were performed for IPMN; of these, 852 (37.7%) had IPMN-I. IPMN-I comprised 33.3-42.5% of resected IPMN annually. Patients with IPMN were older (67.4 versus 63.0 years, p<0.001) and less likely to undergo pancreaticoduodenectomy (53.9% versus 62.6%, p<0.001) or vascular resection (4.8% versus 14.9%, p<0.001) compared non-IPMN patients. Those with IPMN experienced fewer major complications (31% versus 39.9%, p<0.001) but similar rates of CR-PF (12.7% versus 13.8%, p=0.09) than the non-IPMN cohort. Mortality was lower (0.8% versus 1.5%, p<0.001) and LOS was shorter (8.8 vs 9.3 days, p<0.001) in those with IPMN compared to non-IPMN patients.Conclusions: Surgical outcomes for patients with IPMN compare favorably to those undergoing pancreatectomy for non-IPMN indications. However, selecting the appropriate candidates for surgery remains challenging as the majority of IPMN that are resected lack high-grade dysplasia or invasive disease.Abstract ID: 65Veteran Preferences for the Treatment of Intermittent Claudication: A Stakeholder Engagement ProjectIntroduction: Peripheral artery disease (PAD) affects millions of Americans and is particularly prevalent among Veterans secondary to tobacco use. PAD typically presents as intermittent claudication (IC), pain with walking due to reduced lower extremity blood supply. Unfortunately, treatment for IC is limited due to poor compliance with lifestyle modification, limited medication effectiveness, and lack of durable symptomatic improvement with surgical revascularization. We assessed Veterans’ treatment preferences and willingness to participate in prospective studies that evaluate novel IC treatments.Methods:We administered a 9-item, in-person questionnaire to Veterans with IC at VAPHS vascular surgery clinic. The survey was approved by experts in vascular surgery and qualitative research after an iterative review assessing the relevance and clarity of items. Open- and closed-ended questions assessed i) IC symptoms, ii) prior and future treatment preferences, and iii) willingness to participate a clinical trial. Categorical responses were compared with chi-squared testing.Results: We surveyed 48 Veterans with symptomatic IC (5/2019-12/2019). Of these, 63% (n=30) reported daily activity limitations (DAL) due to IC. Veterans with DAL reported significantly shorter total walking distances compared to Veterans without DAL (p 1 block (n=16), 33% between 1-3 blocks (n=10), and only 10% >3 blocks (n=3). Greater than 2/3 of patients without DAL endorsed walking >3 blocks. Of Veterans who verbalized an ideal treatment (n=34, 71%), 32% preferred medical therapy (n=11), 15% an exercise regimen (n=5), and 29% surgery (n=10) yet 12% explicitly expressed disinterest in surgery (n=4). When directly asked about their interest in medical therapy for IC, 79% were interested (n=38) and 54% were willing to participate in a clinical trial evaluating such therapies (n=26). Conclusion:Veterans with IC report DAL, are interested in non-surgical interventions to improve their symptomatology, and are willing to participate in trials evaluating such therapies.Abstract ID: 66Application of Telemedicine Technology Utilizing Remote SurgeonsIntroductionTelemedicine can ameliorate physician shortages, improve patient access, enhance trainee education, enable continuity of care and facilitate sharing expertise through real time telementoring. MethodsWe describe the initial phase of telemedicine implementation in the OR for quality improvement at a single institution utilizing VisitOR 1 robotic platform during elective surgical cases. Metrics measured included time to connect (2 minutes), audio quality rating by remote and intraoperative surgeons (good, fair, poor), video resolution rating by the remote surgeon (good, fair, poor), remote device type (laptop, phone), remote surgeon locations (same facility, not same facility, international).ResultsFrom June,1 to July 31, 2019, 15 elective surgical cases (open, laparoscopic and robotic) piloted the remote presence of a second surgeon through the VisitOR1 Karl Storz robotic platform. 14 out of 15 (93%) cases took less than 2 minutes to connect to the platform by the OR team. The OR surgeons rated 14 cases (93%) as good audio quality, with one case being fair. In all cases, audio quality was rated good by the remote surgeon. In 3 cases the remote surgeon utilized a mobile phone and a laptop in 12 cases. In one case the remote presence of two remote surgeons were involved (one utilized phone, one utilized laptop). Video resolution was poor in one case (laptop), fair in 4 (1 phone, 3 laptops) and good in 11 (73%). The locations of the remote surgeon were international (England) in one case, a different hospital in two cases and in the same facility in 12 cases. ConclusionsThe application of telemedicine in the OR is feasible and is beneficial in cases where specialists are not readily accessible, providing additional expertise for guidance or improving continuity of care for future visits. As technology improves, the scope of telemedicine will likely expand to all arenas including the OR.Abstract ID: 67Bassini Inguinal Hernia Repair: Does It Still Have A Role Today?Introduction:Originating in 1889, the Bassini technique has long been regarded as the first efficient inguinal hernia repair technique. This technique has been used successfully in thousands of patients, but has been largely superseded by mesh repairs in recent years. This study analyzed our experience with the Bassini inguinal hernia repair in individuals who refused the use of mesh and preferred their own tissues to be used for repair.Methods:After obtaining IRB approval, 203 patients from our Veteran’s Hospital that obtained a Bassini type inguinal hernia repair from 2006-2014 were retrospectively analyzed. Recurrence and postoperative complications were identified with follow up clinic visits. Length of follow up was determined by the last clinical note without recurrence.Results:Two hundred and three patients (ninety-nine percent male) were evaluated with a mean age of 65±12 years old. Recurrence was noted in eight patients (3.9%) and five of these were subsequently re-repaired. Twenty-two patients (10.8%) had a hematoma/seroma postoperatively. Four patients (2.0%) experienced testicular ischemia without the need for orchiectomy, and seventeen patients (8.4%) developed postoperative urinary retention. Forty-nine patients (24.1%) died during the follow-up period with an average survival time of 55±38 months after hernia repair; no death was related to the hernia repair itself. The mean follow-up time for all patients in the series was 64 months.Conclusion:In our experience, only eight patients (3.9%) had a documented recurrence and of these five underwent re-repair. Complications were still minor and easily managed. This study demonstrates that the Bassini repair still remains a viable option for primary inguinal hernia repair, especially in individuals who prefer that mesh not be used.Abstract ID: 68Lung-targeted Peptide Amphiphile Nanofibers for Intravascular Treatment of Pulmonary HypertensionIntroduction: Pulmonary hypertension is a highly morbid disease. The goal of our lab is to develop an intravascular nanotherapy that specifically targets the diseased lung. Pathophysiological changes in pulmonary hypertension lead to significant upregulation of two proteins within the pulmonary vasculature, angiotensin converting enzyme (ACE) and receptor for advanced glycation endproducts (RAGE). Thus, we hypothesize that ACE- and RAGE-targeted peptide amphiphile (PA) nanofibers will localize to the lung in a hypoxia-induced pulmonary hypertension model. Methods: Three ACE-targeted (TPTQQ, GNGSGYVSR, and RYDF) and three RAGE-targeted (LVFFAED [LVFF], KGVVKAEKSK, and AMVTTACHEFFEH) PAs were synthesized. Nanofiber formation was assessed with conventional transmission electron microscopy (TEM). 8-10 weeks old male and female C57BL/6J mice were exposed to chronic hypoxia (10% FiO2) for 3 weeks. Control mice were kept at room air. Mice were administered the PA nanofibers (20mg/kg) via tail vein injection. Lungs were harvested at 30 minutes, and nanofiber fluorescence was quantified with light sheet fluorescent microscopy as number of fluorescent spots per mm3 lung volume. N=3-8/treatment group.Results: Five of the ACE- and RAGE-targeted PAs formed nanofibers on TEM. The RAGE-targeted LVFF-PA nanofiber demonstrated the greatest localization in hypoxic lung tissue and was 1,100-fold greater than the ACE-targeted TPTQQ-PA (465±94 vs. 0.4±0.2 spots/mm3, p=0.000028). Interestingly, the LVFF-PA nanofiber had 43-fold higher localization in female compared to male hypoxic lungs (939±90 vs. 22±11 spots/mm3, p<0.0001). There was no difference in localization between hypoxic and control lungs treated with the other ACE- and RAGE-targeted PA nanofibers, and non-targeted PA nanofiber showed minimal fluorescence in hypoxic lungs (1.6±1.1 spots/mm3, p=0.00003).Conclusion: Our study demonstrates the successful creation of a novel, intravascular nanomaterial that targets the pulmonary vasculature involved in hypoxia-induced pulmonary hypertension. These findings serve as the foundation for the development of an effective nanotherapeutic to treat pulmonary hypertension.Abstract ID: 69Incidence and Risk Factors for Intensive Care Unit (ICU) Delirium after Traumatic Brain Injury (TBI)INTRODUCTION: We sought to identify the rate and independent predictors of delirium among intensive care unit (ICU) patients with traumatic brain injury (TBI). We hypothesized that unique injury characteristics would be associated with risk of TBI-associated delirium. METHODS: This six-year single center retrospective cohort study evaluated individuals >16y with blunt TBI needing ICU admission. Delirium was measured using the Confusion Assessment Method-ICU (CAM-ICU). Outcomes were delirium days among survivors, and delirium- and coma-free days (DCFD) within the first 14 days. Multivariable logistic regression modeled delirium duration. Proportional odds logistic regression modeled DCFD. For both models, covariates consisted of age, sex, insurance type, Marshall head CT classification, subarachnoid hemorrhage (SAH), Injury Severity Score (ISS), need for cardiopulmonary resuscitation, maximum admission motor score, glucose, hemoglobin, and pupil reactivity. For brevity, outcomes with significant P-values reported.RESULTS: The cohort of 2,664 TBI patients had an 80.1% hospital survival rate. Median ISS was 27 (IQR:20-36); over 75% had Marshall Class II-IV and 50% had SAH. Delirium prevalence was 60%, lasting a median duration of 4 days (IQR:2-8). Older age, higher ISS, maximum motor score <6, Marshall Class II–IV, and SAH were associated with risk of increased delirium duration (all P<0.001). Odds of higher DCFD were associated with younger age, female sex, lower ISS, motor score of 6, Marshall Class I, absence of SAH, and higher admission glucose and hemoglobin levels (all P<0.01).CONCLUSIONS: In this large cohort, ICU delirium after TBI affected 3 out of 5 patients with a median length of 4 days. Age, general injury severity, motor score, and features of intracranial hemorrhage were predictive of TBI-associated delirium. Given the high prevalence and impact on hospitalization, further work is needed to understand the impact of delirium and TBI on outcomes, and if delirium risk can be minimized.Abstract ID: 70Obesity in Lower Extremity Amputation – What is the Relationship?IntroductionAn astounding 71.3% of adult Americans were categorized as overweight or obese in 2016 leading to a national health care crisis.1 Obesity is associated with decreased life expectancy, higher incidence of malignancy, and with metabolic syndrome.2 Interestingly, obesity has a paradoxical protective effect especially in the setting of end stage renal disease.3 We set forth to examine the relationship between obesity and post-operative outcomes after lower extremity amputations as captured in the Veteran Affairs Surgical Quality Improvement Program (VASQIP) database.MethodsWith IRB approval, retrospective review of the VASQIP national database was undertaken for all patients who underwent lower limb amputations between 2005 and 2018. All patients were differentiated into one of four groups based on BMI calculation at the time of their amputation (normal 18.5-25 m/kg2, underweight 30 m/kg2). Univariate and multivariate forward logistic regression models were employed to evaluate the associations between the BMI classes. ResultsThere were 26,526 lower extremity amputations between 2005 and 2018. These patients had a mean age of 66.1 ± 10.1 years old and 98.6% (n=26,168) were male. The average BMI was 27.0 ± 6.9 m/kg2 and 57.1% (n=15,105) were overweight or obese. Obesity was associated with renal complications (p<0.001) and longer lengths of stay (p<0.006). Underweight patients had higher rates of death (<0.001) and pulmonary complications (<0.001) (Table I). However, when risk adjusted, BMIs was not associated with higher risk of complications and had a lower risk of death (Table II).ConclusionBMI appears to have minimal impact on lower extremity amputation patients than what would be suspected. Interestingly, the paradoxical protective effect of obesity was also found in this study. Future work will focus on assessment of other factors and accurate assessment of risk of post-operative complications and death.Abstract ID: 71Patient frailty and postoperative mortality after non-cardiac surgery – does specialty matter?Introduction:Patient frailty is known to be an important risk factor for adverse surgical outcomes, even after low-risk procedures. The distribution of high- vs. low-risk procedures varies between surgical specialties, and it is unknown whether frailty has a differential impact on postoperative mortality across surgical specialties.Methods:We performed a retrospective analysis of patients undergoing non-cardiac surgery in nine specialties from 2010-2014 in the Veterans Affairs Surgical Quality Improvement Program (VASQIP, N=471,296) and National Surgical Quality Improvement Program (NSQIP, N=2,339,031). Patient frailty was ascertained using the Risk Analysis Index (RAI), grouped into 4 categories (≤20 “Robust”; 21-29 “Average”; 30-39 “Frail”; ≥40 “Very Frail”). A previously published Operative Stress Score (OSS) was assigned to procedures [range 1-5; 1/2=low, 3=modest, 4/5=high]. Multivariable logistic regression models were calculated to evaluate associations between frailty and mortality (30-day, 180-day) adjusting for OSS and emergent status. Regression models were calculated for the combined dataset and stratified by nine specialties.Results:The distribution of frailty (p VASQIP 180-day mortality: Very Frail vs. Average aOR 17.9 (17.0-18.6); Frail vs. Average aOR 5.1 (4.8-5.3); OSS 4/5 vs. 1/2 aOR 2.8 (2.6-2.9)]. Stratified by surgical specialty, results were similar except for neurological, orthopedic and plastic surgery in NSQIP where OSS 4/5 rather than frailty demonstrated the highest aORs [e.g. Neurosurgery 30-day mortality: OSS 4/5 vs. 1/2 aOR 18.2 (13.8-24.1)]; Very Frail vs. Average aOR 9.8 (7.7-12.5); Frail vs. Average aOR 4.2 (3.6-4.9).Conclusion:Frailty appears to be a dominant factor associated with postoperative mortality across all non-cardiac surgical specialties independent of operative stress. Thus, preoperative frailty assessment should be implemented for all specialties regardless of the planned procedure to facilitate risk stratification and shared decision-making.Abstract ID: 72Optimal Medical Therapy Varies by Risk Factors for Cardiovascular Disease Among Veterans Evaluated in Vascular Surgery ClinicIntroduction:Cardiovascular disease (CVD) is the leading cause of mortality in the US and is particularly prevalent among Veterans. All patients with coronary artery disease (CAD) and CAD risk-enhancing factors (CADref), defined as peripheral arterial disease (PAD), chronic kidney disease, and diabetes, have an increased risk of future CVD. Optimal medical therapy (OMT), including anti-platelet and statin therapy, smoking cessation, blood glucose and pressure control reduce these risks. The rate of Veteran OMT is unknown but likely poor. Therefore, we created an evidence-based checklist to quantify risk factors and OMT among Veterans in the vascular surgery clinic. Methods:We created an evidence-based checklist assessing CAD, CADref associated risk-factors (i.e., smoking and hypertension), and five OMT (i.e., smoking status, anti-platelet and statin prescriptions, blood glucose, and pressure control), and implemented it for all Veterans evaluated at VAPHS vascular surgery clinic. We excluded Veterans not meeting criteria for OMT (i.e., venous disease) or those for postoperative follow-up. Checklist completion, prevalence of risk factors, and OMT use were reported.Results:From 9/11/19 to 12/18/19, 388 checklists were collected. 336 (87%) patients met inclusion criteria and 285 (85%) checklists were filled out to completion. Of these, 176 (62%) patients had PAD, 85 (30%) were smokers, 91 (32%) had diabetes, and 198 (70%) had hypertension. Overall, 123 (37%) had complete OMT across all modifiable risk factors. 268 (85%) patients were already prescribed an anti-platelet medication and 216 (76%) a statin. The rate of OMT varied by risk factors: 77 (85%) diabetics had a HemoglobinA1c<8.0%, and 166 (84%) hypertensive patients had a systolic blood pressure <140 mmHg. Conclusions:Veterans at vascular surgery clinic have a high prevalence of modifiable CVD risk factors. While three quarters are receiving OMT for each individual risk factor, only about a third are optimized across all risk factors, leaving significant room for improvement.Abstract ID: 73U937 Macrophage Effect on Vascular Smooth Muscle Cell Phenotype and the Effects of Altered MYD88 Macrophage Expression on Smooth Muscle PhenotypeIntroduction The immune response to implantation of lower extremity bypass graft influences vascular smooth muscle cell (VSMC) remodeling which effects to long term graft outcomes. A previous study from our lab identified upstream gene regulators in circulating monocytes showing distinct patterns within 24 hours of surgery that had an effect on graft patency at 12 months. To investigate the effect of upstream regulators in monocytes and macrophages and their subsequent effect on VSMCs, we needed to develop a reliable model to detect early, 24 hour, changes in VSMC biology. We hypothesized that exposure to macrophages would drive VSMC phenotype from contractile to synthetic, and that altered expression of the upstream regulators would promote the contractile SMC phenotype.MethodsU937 human monocyte cells (or U937 MYD88 knockdown monocytes) were cultured with PMA to differentiate into macrophages (M0). M0 Cells were treated with IFN-&gamma; and LPS or IL-4 to induced polarization to M1 or M2 phenotype. Phenotype specific macrophages were co-cultured with arrested aortic VSMCs for 24 hours. VSMCs RNA was isolated, a cDNA library was created. ACAT2 (αSMA) and TAGLN (SM22α) VSMC expression levels were then measured via RT-PCR. ResultsVSMCs cultured (treated) with M0, M1, or M2 cells expressed ACAT2 and TAGLN at lower levels than untreated VSMC cells. M0 ACAT2, 1.52 vs 0.14 (p=0.007) and TAGLN, 1.28 vs 0.16 (p<0.001). M1 ACAT2, 1.52 vs, 0.10 (p=0.006) and TAGLN, 1.28 vs 0.22 (p<0.001). M2 ACAT2, 1.52 vs 0.15 (p=0.007) and TAGLN, 1.28 vs 0.23 (p=0.003). There was a non-statically significant increase in TAGLN expression in VSMC treated with MYD88 knockdown M0, M1, and M2 macrophages.ConclusionsVSMC phenotype shifts from contractile toward synthetic within 24 hours of exposure to macrophages. Knockdown of MYD88 appears to shift VSMC phenotype back to the contractile form. This interaction needs further investigation.Abstract ID: 74SURGICAL TREATMENT OF COMPLICATED AND UNCOMPLICATED DIVERTICULITIS: A COMPARITIVE STUDY OF ROBOTIC, LAPAROSOPIC AND TRADITIONAL OPEN APPROACHES AMONG THE VETERANS OF BRONX, NEW YORK CITY.Background:This study compares surgical procedures done for the treatment of diverticulitis among the veterans of The Bronx, NY. We evaluated the feasibility and safety of robotic-assisted laparoscopic surgery (RALS) for diverticulitis and compared the results of robotic, laparoscopic and open approaches. Cases were classified as complicated if they had perforation, fistula, obstruction or abscess. Methods:Between 2011-2019, all patients who underwent surgical treatment of diverticulitis were studied. RALS was performed in 5 patients, laparoscopic resection was performed in 8 patients, while open resection was also performed in 8 patients. We assessed demographic data, intraoperative parameters, and postoperative outcomes along with reoperation and fistula healing rates. Results:A total of 21 patients underwent surgery. The mean age and BMI were (57.2±9.3 years) and (29.9±6.3kg/m2) respectively. Disease stratification identified 4 cases of uncomplicated (19%) and 17 cases of complicated (81%) diverticulitis. In the laparoscopic group, there was 1 conversion and 1 ureteral injury. Open complications were abscess formation and an entero-colonic fistula. The length of hospital stay among robotic, laparoscopic and open groups was 6.6±2.09 days, 8.7±4.9 days, 10.1±8.0 days and the postoperative complication rate was 0% (n = 5), 12.5% (n = 8) and 25% (n = 8) respectively. There were no anastomotic leaks, secondary surgical interventions, or readmissions in any group.Conclusions: This retrospective review demonstrated that RALS is a safe and feasible option for surgical treatment of diverticulitis. The approach may be offered to patients with uncomplicated or complicated disease. It results in a short hospital stay and fewer complications. Our study limitations were small sample size and retrospective review. Additional studies are needed to further evaluate the role of robotic surgery in patients with complicated and uncomplicated diverticulitis. Keywords: Diverticulitis, Robotic surgery, Laparoscopic surgery, Complications.Abstract ID: 75A MULTICENTER STUDY OF OUTCOMES AND SURVIVAL BENEFITS AFTER COLORECTAL CANCER RESECTIONS: COMPARISON BETWEEN OPEN, LAPAROSCOPIC & ROBOTIC APPROACHES AMONG VETERANS IN NEW YORK CITYIntroduction: Various centers commonly use either traditional open or laparoscopic approaches for colorectal cancer resections, while at the same time we are seeing a growing trend towards Robotic colorectal surgery. Our objective is to compare early and long-term outcomes between open, laparoscopic and robotic colorectal resections for cancer among veterans in New York City. Methods: This study was designed to compare open, laparoscopic, and robotic colorectal surgery outcomes in VA hospitals serving the needs of the New York Metropolitan Area. Logistic and multiple linear regression analyses were used to compare 1 week, 30-day and 1-year colorectal outcomes in the New York Metropolitan Area Veterans Population databases. The primary outcome was overall short and long-term post-surgical mortality and complications. Secondary outcomes were operative time, day to diet resumed, length of stay, conversions, rate of positive resection margins and lymph nodes harvested. Only patients undergoing elective colorectal resection were included.Results: A total of 200 patients met the inclusion criteria. Overall complications, postoperative ventral hernias and surgical site infections were significantly favorable for the robotic and laparoscopic approaches compared with the open approach. Short-term mortality and anastomotic leaks were significantly fewer for the laparoscopic and robotic approaches compared with the open approach. Robotic resections were associated with a decreased length of stay. There was no inferiority in marginal status and number of lymph nodes harvested.Conclusions: Among the veterans, minimally invasive colorectal surgery is associated with fewer complications and has several other outcomes advantages compared with the traditional open approach. A prospective randomized trial is needed to confirm these findings. Keywords: Colorectal cancer, Laparoscopic colon resection, Robotic-assisted laparoscopic colon resection, Colorectal surgery, outcomes.Abstract ID: 76Stereotactic Ablative Radiosurgery for Treatment of Limited Pulmonary MetastasesIntroduction: Stereotactic ablative radiosurgery (SABR) is an effective treatment of metastatic cancer of the lung in the oligometastatic setting with an evolving role. We report outcomes of a series of patients treated with SABR for pulmonary metastases.Methods: We retrospectively reviewed outcomes of 45 patients treated with SABR at our center for limited pulmonary metastases. Patients were selected using a multidisciplinary approach and procedures were performed by thoracic surgeons in collaboration with radiation oncologists. Rates of disease recurrence and survival were assessed.Results: 45 patients (26 male, 19 female) with median age 64 (range 30-89) were treated with SABR for 54 metastatic lung lesions. Primary tumor histology included colorectal (n=14), head and neck (n=6), breast (n=5), and other (n=20). Median follow-up after treatment was 27 months. Median disease-free interval after primary tumor control was 30 months. Median time to first lung metastasis was 34 months. Peri-procedure (30-day) mortality was 0%. SABR was performed as the first local treatment (n=23, 51%) or after prior failed local treatment (n=22, 49%). In select cases, SABR was utilized in conjunction with surgery (n=1) or radiofrequency ablation (n=2). Cancer recurrence was noted in 31 patients (69%), with 12 month median time to recurrence (95% CI [8 – 34]). Recurrence in the treated tumor was observed in 12 patients (27%). A median survival of 27 months (95% CI [22 – 49]) after treatment was observed. The 2-year and 5-year overall survival was 62% and 29%.Conclusions: This study demonstrates the safety of SABR treatment of limited pulmonary metastases. The results demonstrate reasonable survival in this high risk cohort, often having failed prior treatment, in the metastatic setting. SABR represents a minimally invasive option for patients with lung metastases unfit for surgical resection. Future studies are needed to define the role of SABR alongside other ablative therapies and surgery.Abstract ID: 77Predictors of Mortality and Readmission for Acute Mesenteric IschemiaIntroductionAcute mesenteric ischemia (AMI) is associated with significant morbidity and mortality. There is a paucity of published data on rates and reasons for readmission in this population. The purpose of this study is to determine the rate and predictors of mortality and 30-day readmissions among patients with AMI MethodsThe 2013-2014 Nationwide Readmission Database was queried for adults admitted with a principal ICD-9-CM diagnosis code of acute mesenteric ischemia. Demographics, comorbidities, hospital characteristics, and type of intervention using ICD9-CM procedure codes (open versus endovascular) were evaluated. Outcomes of interest were mortality and 30-day readmission. Multivariate binary logistic regression was performed to identify significant predictors of outcomes.ResultsThere were 1907 patients included in the query. Mortality was 28.9% (n=551) during index admission. Independent predictors of mortality included open surgery [OR 1.96, (1.55-2.50)], small hospital [OR 1.96, (1.24-3.11)], and primary payer [Medicare OR 1.8 (1.23-2.66), Medicaid OR 2.5 (1.48-4.08), Self-Pay OR 3.1 (1.61-5.90)]. Overall 30-day readmission rate was 20% (n=267). The rate of readmission was lower for open repair compared to endovascular [21.2% vs 17.7%, p<.001; OR 0.71(0.53-0.96)]. The most frequent reasons were for non-bleeding gastrointestinal conditions (27%) followed by cardiovascular and cerebrovascular events (11%) and treatment/procedure-related events (10%).ConclusionsPatients who underwent open repair, were treated at small hospitals, or had government funding had higher mortality. Nearly a third of readmissions were due to non-hemorrhagic gastrointestinal complications. This study provides important information on potential complications leading to readmission in revascularized AMI patients.Abstract ID: 78A Neural Network Model to Identify Mesh Infection Following Hernia SurgeryIntroductionMesh infection is serious complication of hernia surgery. These infections are often latent and are not identified by routine surveillance. We aimed to develop and validate a prediction score for mesh infection and incidence of explantation.MethodsA national database of Veterans undergoing hernia surgery between 2008-2015 from VASQIP was created. Medical record review was performed on a sample with the goal of finding cases with true mesh infection within 5 years of surgery. A neural network model was then fit on the chart-reviewed cases. The model assigned a probability of mesh infection to each patient, based on occurrence of a positive culture, imaging study, antibiotic prescription, fever and elevated WBC for each 90-day postoperative interval. Additional variables included type of hernia repair, age, sex, and BMI.The model was trained on a random sample of 75% (674) of chart-reviewed cases. Predictions were made on the remaining 25% (230) to validate the model. Performance was measured using the area under the receiver operator characteristics curve (AUC). We then evaluated mesh infection and mesh explantation in the cohort of hernia surgeries.ResultsAmong 96,440 hernia surgeries, the AUC for identification of true mesh infection in the training dataset was 0.88 and for the validation set was 0.89. In 428 patients with >80% probability of mesh infection, the true rate in a 10% sample of chart-reviewed cases was 72% (28/43). Among 334 mesh explantations for infection, 93 were in the group of 80% probability or higher. The mean time from surgery to mesh infection in this group was 270 days, and 386 days to explantation. ConclusionsWe built a model that detected patients with mesh infection, many of which are subsequently explanted. This score can be utilized to optimize management of patients at risk of mesh infection and understand factors associated with subsequent explantation and its prevention.Abstract ID: 79Neuronal Fibrosis is Increased in Peripheral Arterial Disease (PAD) but Does Not Impact Wound Healing In Veterans Undergoing Major AmputationBackground: PAD is highly prevalent in Veterans undergoing major amputation, and PAD impacts wound healing and neuronal fibrosis. The impact of neuronal fibrosis on wound healing after major amputation is not well understood but could influence amputation site. Our objective was to test if neuronal fibrosis affected wound healing and to compare absolute collagen content of tibial nerves from patients with and without PAD. Methods: 28 (67 Years +/-8) male Veterans with PAD undergoing (30) major amputation were consented prospectively to participate in an IRB approved study testing the impact of neuronal fibrosis on post-operative healing. 9 had prior contralateral amputations; 6 had revisions. Healthy cadaver nerves (50 Years +/-17) were used as the control. Neuronal fibrosis was quantified by total collagen content, Raman spectroscopy and histology. Results were segregated in patients with and without microvascular disease, and wound healing over time was quantified.Results: At a mean follow-up of 30 months, there were 10 deaths (4/8 unhealed). Increased neuronal fibrosis did not correlate with wound healing, but PAD patients had 5 times more collagen than non-PAD samples (P=.0004) and had a distinct signature by Raman spectroscopy. Histologic changes were present in 7/8 PAD nerves that underwent histology, but histologic abnormalities were mild compared to collagen content and Raman measurements. Wound healing and revision rates were not significantly different between patients with and without microvascular disease. Conclusion: Neuronal fibrosis is significantly increased in PAD but not linked to wound healing. We found total collagen content to be the most sensitive measure of neuronal fibrosis in the tibial nerves, but PAD nerves also segregated from nerves in non-PAD patients under Raman spectroscopy imaging. We are currently building a wound healing model with this data for use in integrating clinical and biometric data for use in decision-making for below knee amputation candidates.Abstract ID: 80The Impact of Pulsed Electromagnetic Fields (PEMF) on Postoperative Pain in Patients Undergoing Cardiothoracic SurgeryIntroduction:The opioid epidemic is a public health emergency. Postoperatively, opioids increase morbidity and LOS. Multimodality pharmacotherapy is used to decrease postop opioids. Pulsed electromagnetic field therapy(PEMF) has been previously shown to significantly decrease pain, and inflammation. Our objective was to evaluate the impact of PEMF (a disposable small battery-powered generator connected to a malleable 15 cm diameter electrical coil – SoftPulse? - average electric field of 32 +/- 6 mV/cm) on postoperative pain and narcotic usage in patients undergoing cardiothoracic surgeries.Methods:A prospective database of elective CT patients undergoing open cardiac and thoracic procedures was queried from 1-1-19 to 12-31-19. Starting on 8/2019, patients had PEMF device placed on their dressings in the OR. Demographics, comorbidities-COPD, CAD, tobacco-use, EtOH-use, opioid-use, and BMI were collected. Mean pain scores(VAS,0-10), total opioid usage, and LOS were collected. An opioid conversion calculator was used to convert daily opioid use into morphine equivalent dose(MED). All patients in both groups had the same multimodality pharmacotherapy postoperative pain control orders per established CT ERAS pathway. Univariate analysis was performed between groups.Results:31 patients were analyzed(PEMF=16, NO-PEMF=15). Both groups were well matched with no significant differences in age, BMI, gender, comorbidities, ETOH, tobacco, hx of opioid use, or procedure performed. There was a significant reduction in pain VAS of 40%, on POD1, and 50% POD3 in the PEMF(POD1=3±1; POD3=2±1) vs. NO-PEMF(POD1=5±-1; POD3=4±-1), both p < 0 .006. There was a significant reduction in the total opioids used of 70% in the PEMF(MED=72.3±13.3) vs. NO-PEMF(MED=245±37), p=0.0007. The median LOS was less in the PMEF- 4 days, vs. NO-PMEF – 6 days.Conclusions:The use of PEMF significantly decreased postoperative pain VAS by 50% and opioid requirements by 70% with an associated decrease in LOS by 2 days. The use of PEMF should be considered in the postoperative pain management of surgical patients to decrease opioid requirements.Abstract ID: 81Improving Operating Room Lag Time Compliance at a Level 1a Veterans Affairs HospitalIntroduction: Operating room lag times (LT) greatly impact the flow of surgical services at hospitals. Delays in LT lead to patient and staff frustration, longer work days, and fewer cases completed. The National Surgery Office (NSO) sets metrics for LT based on case complexity and assigns VA hospitals a score of 1-4 based on percent of met LTs. Historically our facility has had a consistently low score of 1 ( 55%). Methods: A multidisciplinary committee consisting of surgical, perioperative nursing, anesthesia, environmental services, and sterile processing staff met monthly beginning in February 2019. We began tracking LT data including reasons for delays. Interventions included defining and standardizing LT metrics, improving staff education and communication (2/2019), and targeting timeliness of procedural consents (4/2019). Project progress was updated weekly on a public dashboard and via a large multidisciplinary stakeholder meeting in 9/2019. Data was collected weekly and analyzed via t-tests using STATA (College Station, TX). Results: Pre-intervention operating room LT were retrospectively analyzed from 2018. Post-intervention data were prospectively collected and analyzed from 2/2019-12/2019. Monthly trends of percent met LT show a significant improvement from score 1 (<40% compliance) to score 4 (>=70% compliance) by 12/2019. Average LT for 2019 were significantly shorter than 2018 times (43.0 vs 47.1, p<0.01). In the last quarter, LT were reduced to an average of 33.0 min. The top four reasons for delays identified were add-on cases (not true lags) (27%), room set up (18%), consent (16%), and environmental services (9.8%). Conclusion: Quality improvement efforts had substantial positive impact on VA OR lag time compliance with improvement from 70% within a year. Primary interventions centered on clearly defining and communicating metrics, goals, and progress with stakeholders.Abstract ID: 82Detecting anal dysplasia in veterans living with HIV: improvement in screening rate using a multidisciplinary protocolIntroduction: Anal cancer has been increasing in incidence with human immunodeficiency virus (HIV)-infected patients representing the highest risk group. Anal cancer precursor lesions (anal dysplasia) can be detected with screening anal Papanicolaou (Pap) tests. A national Veterans Affairs (VA) guideline recommends annual screening of all HIV-positive patients. Guideline adherence requires trained specialists and resources. In 2018, the Madison VA implemented a multidisciplinary protocol to improve screening. Our objective was to evaluate screening rates and disease detection before and after the protocol. Method: HIV-positive patients eligible for anal dysplasia screening at William S. Middleton Memorial Veterans Hospital from 2010 to 2019 were included. Demographics were collected including age, sex, and smoking history. Chart review was performed to identify the use of anal Pap tests. Number of patients diagnosed with advanced disease (high-grade dysplasia or anal cancer) via cytology screening or symptomatic presentation were recorded. Result: 120 patients with HIV infection were eligible for anal dysplasia screening during the study period. The average age of our cohort was 58 years old, 98% were males, 62% of them had a history of smoking, and of those with known sexual history 66% had a history of anal receptive intercourse. Anal dysplasia screening rate increased from 12% to 40% after program implementation. Prior to the program, 29% of advanced disease was detected with a screening test while the remaining 71% were detected after symptoms had already developed. After the program, all newly diagnosed advanced disease was detected with screening prior to symptom development. Conclusion: Implementation of a multidisciplinary screening program for anal dysplasia is feasible within a VA system and can improve guideline adherence. An increase in screening rate in this population has the potential to detect advanced disease prior to symptom development.Abstract ID: 83Delays in Adjuvant Chemotherapy in Locally Advanced Rectal Cancer is Associated with Decreased SurvivalIntroduction: Adjuvant chemotherapy (AC) after neoadjuvant chemoradiation (CRT) and surgical resection (SR) has been the standard of care for stage II and stage III rectal cancer, except where total neoadjuvant therapy is given. However, there is no consensus regarding the optimal timing to begin AC for rectal cancer. Our study aims to evaluate the effect of AC timing for rectal cancer on overall survival. Methods: The National Cancer Database (NCDB) from 2004 to 2016 was queried for patients with single primary stage II or III rectal cancer who had undergone CRT followed by SR and AC. Patients were stratified based on timing of AC from SR date (early 8 weeks). The Kaplan-Meier method was used to estimate overall survival probabilities. Multivariate logistic modeling was used to compare clinical outcomes.Results: A total of 8,722 patients were identified, of which 905 (10.38%) received early AC, 4,621 (52.98%) intermediate AC, and 3,196 (36.64%) delayed AC. Of these patients, pathological lymph node metastasis was positive (ypN+) in 73% of patients undergoing early AC, 74% intermediate AC, and 63% delayed AC (p<0.05).The five-year survival probability was 71.1% (95% CI 68%-74%) for patients receiving early AC, 73.2% (95% CI 72%-75%) intermediate AC, and 65.8% (95% CI 64%-68%) delayed AC. Using multivariate analysis, patients who underwent delayed AC had an associated decreased survival compared to patients receiving early AC (odds ratio of 1.25; 95% CI 1.02-1.52) and intermediate AC (odd ratio of 1.38; 95% CI 1.2-1.59) (p<0.05).Conclusions: Delay in the administration of AC is associated with decreased five-year survival. Compared to either early AC or intermediate AC groups, patients in the delayed AC group were observed to have an increased risk of death, despite having a lower proportion with ypN+ disease.Abstract ID: 84Shared Decision-Making Tool & Opioid Prescribing in Hand Surgery in VeteransIntroduction: Orthopedic surgeons can reduce the percentage of opioids prescribed to patients by 34% to 68% without compromising pain control. The goal of this study is to determine if an educational patient-centered decision-making tool designed to individualize pain management and maximize non-opioid over-the-counter (OTC) medications reduces opioid use and waste while maintaining adequate pain relief.Methods: Adult patients undergoing soft tissue surgeries were consented. Patients were randomized to an educational tool group or standard of care and surveyed for 4 weeks after surgery. Survey variables of interest included PROMIS Pain Intensity, and Pain Interference as well as amount of opioid pain medication taken, and OTC medications utilized. Statistics included chi-squared, wilcoxon rank sum, and welch’s t-tests.Results: A total of 28 patients participated with a mean age of 59.5, 11 in the educational tool group, and 17 who were only surveyed. Educational tool group averaged 6 prescribed opioids pain pills versus[KB1] 10 for the no tool group (P=0.0087). The median opioid pills taken the first week after surgery was 4 (IQR: 7) for the tool group and 3 (IQR: 5) for the no tool group (P=0.8105). PROMIS scores focusing on pain intensity and interference were not significantly different the 1st week after surgery. Week 2 postoperative pain interference scores were lower in the shared tool group (49.1 vs 55.7, P=0.0398) while pain intensity scores were not significantly different (39.8 vs 43.4, P=0.1524). Week 3 and 4 pain interference and intensity scores were lower in the educational tool group, but not statistically significant.Conclusion: The educational tool group presented with equivalent or better pain control and while being prescribed a lower amount of opioid pain pills than the usual care group. Shared decision making strategies applied to other outpatient orthopedic surgical setting may help reduce the amount of opioids prescribed withoutAbstract ID: 85Long term survival in Veterans undergoing surgery for asymptomatic carotid disease varies by risk statusIntroduction: Carotid intervention via endarterectomy (CEA) or stenting (CAS) is not recommended for asymptomatic patients with < 5 years life expectancy. Contemporary trials e.g. Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) exclude these patients. Recent work shows four chronic conditions (Cs) i.e. Cancer in past 5 years (except localized prostate or skin cancer), Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and Chronic Kidney Disease (CKD) as risk factors predicting lower survival after CEA/CAS. We examined 5-year survival in asymptomatic Veterans undergoing CEA/CAS stratified by risk status.Methods: We identified all Veterans (N=14,037) undergoing CEA (N=12,216) or CAS (N=1821) in the VA between 2010 and 2017. Using data from the VA Corporate Data Warehouse and Medicare data, we stratified Veterans by CREST inclusion criteria, and the presence of “Any C” (Cancer, CHF, CKD and COPD) as well as “Severe C” (CKD glomerular filtration rate < 3 0, CHF or COPD with recent hospitalization, and Cancer). Differences in 5-year survival were assessed using Kaplan Meier analysis. We also assessed 5-year survival in Veterans who had CEA/CAS in non-VA settings.Results: Overall 5-year survival was 72.7% (CEA 73.8% vs CAS 66.2%, p < 0 .001). For CEA, the 5 year survival for those who met CREST inclusion criteria vs those who didn’t was 78.5% vs 63.3% (p < 0 .001). Similarly for CAS, 5-year survival for those who met CREST inclusion criteria vs who didn’t was 73.6% vs 56.1% (p < 0 .001). Five year survival again varied by their risk status: Without “Any C” 79.3%, With “Any C” 61.3%, and With “Severe C” 48.2% (p < 0 .001). Among patients receiving CEA/CAS outside VA 5-year survival was 66%.Conclusion: Veterans who do not meet contemporary trial inclusion criteria or have high risk comorbidities have poor survival after CEA/CAS. Veteran survival post CEA/CAS is comparable within and outside VA. Preoperative tools to predict 5-year survival may help improve patient selection within VA and for referral to the community.Abstract ID: 86Longitudinal Survey Outcome Assessment in a Surgical Randomized Controlled TrialIntroduction:Longitudinal assessment of qualitative outcomes can be challenging in surgical care. We examined our adherence to qualitative outcome assessment as part of the Preferences for Open Versus Endovascular Repair of AAA (PROVE-AAA) randomized trial. Methods:A survey instrument was administered to Veterans considering AAA repair, and the trial compared usual care and a decision aid. Surveys were completed at three time points: (1) at Study Enrollment, (2) 1-month Post-Enrollment, and (3) 1-Month Post-Surgery. We examined how frequently Veterans completed all three surveys and assessed the reasons for missing surveys. Auditing involved local site review and Veteran contact as well as national review of all surveys coupled with multiple attempts to allow for Veterans to complete outstanding surveys.Results:A total of 236 Veterans were randomized at 23 VA hospitals; 110 in the control arm, 126 in the intervention arm. At the time of study enrollment, 235/236 surveys were completed (99.5%). After enrollment, 178 Veterans were eligible to complete a Post-Enrollment survey; 58 patients had surgery before their Post Enrollment Survey was due. Among these 178 eligible Veterans, 160 Veterans successfully completed the Post Enrollment Survey (160/178, 90%). Reasons for the 18 Post-Enrollment protocol deviations varied; four were out of the time window for completion, seven were lost to follow-up, and seven were missing for unknown reasons despite our audit. As of January 10th, 2020, 178 patients had undergone surgery and were eligible for a Post-Surgery survey. Among these Veterans, 158 successfully completed the Post-Surgery Survey (158/178, 89%). Reasons for the 20 protocol deviations among the Post-Surgery surveys included 3 Veterans who refused the survey or died, 8 out of window, 6 lost to follow-up, 1 withdrawal, and 2 unknown despite auditing. Conclusion:The assessment of longitudinal survey outcomes can be achieved in VA multi-center surgical trials but requires auditing to ensure minimal missing data.Abstract ID: 87Time to Surgery and Outcome after VA Community Care Referral for Inguinal Hernia RepairIntroduction: Veterans can obtain healthcare in the community via the Choice and MISSION acts. Eligibility is largely based upon distance from home (>40 miles) or wait time (>28 days). Inguinal hernia repair is the most common procedure performed by general surgeons; therefore, we sought to characterize the outcome after inguinal hernia repair performed in the community after referral from a VA hospital. Methods: Retrospective review of patients referred to community care (CC) from the Eastern Colorado Health System for an inguinal hernia from April 2018 to December 2019. Age, gender, BMI, and other baseline demographics were collected. In addition, the time (days) from placement of CC referral to first appointment and time to surgery were recorded.Results: Over a 20-month period, 73 patients were referred to CC. The majority (49 patients, 68%) were referred due to distance from home, compared to wait time (22 patients, 31%) and best medical interest (2, 3%). Thirty-two (44%) waited an average 40 days (range 0 - 241) to see a CC surgeon and underwent surgery on average 80 days (range 2 – 403 days) after referral. Two (6%) patients suffered an early recurrence. Two (6%) patients suffered significant complications including an ulnar nerve injury and orchiectomy for ischemic orchitis. Forty-one (56%) had not had surgery during an average follow-up of 5 months (0 – 20 months). Of these 41 patients, 13 (33%) were still awaiting surgery, 7 (16%) declined referral, 3 (8%) had no hernia on exam and 2 (5%) the CC surgeon counseled against surgery.Conclusion: The CHOICE and MISSION Acts have improved access for patients who live at great distance from a VA hospital. In our small cohort, surgical outcomes after inguinal hernia repair are within current standards. However, the wait time for consultation and surgery in the community likely exceeds that available at many sites.Abstract ID: 88Sex Bias Remains Prevalent in Surgical Research- 5 Year UpdateIntroduction: Sex bias exists in clinical and biomedical research. Our group previously published a study showing the presence of sex bias in human, animal, and cellular research among 5 surgical journals from 2011-2012. We aimed to investigate if surgical research has become less sex-biased over time. We hypothesized that sex bias has remained unchanged in surgical clinical and biomedical research.Methods: Data was abstracted from manuscript published in 5 surgical journals (Annals of Surgery, American Journal of Surgery, JAMA Surgery, JSR, and Surgery) from 1/1/17-12/31/18. Data included study type, # males/females, and presence of sex-based reporting, statistical analysis, and discussion of data. Data from 2017-2018 were compared to 2011-2012.Results: Of 2,890 articles, 2,523 (86.6 %) included humans, 323 (12.8%) animals, and 88 (3.0%) cells. With respect to human clinical research, comparing 2017-18 to 2011-12 data, more articles reported the sex of the human (86.6% vs 82.7%). Inclusion of both sexes remained high (93.5% vs 94.6%). While fewer articles reported data by sex (35.9% vs 38.1%) and included discussion of sex-based results (10.3% vs 22.9%), a similar number of articles statistically analyzed data by sex (34.6% vs 33.2%). With respect to animal research, while a similar number of articles reported the sex of the animal (79.3% vs 78.0%), more articles included both sexes (8.6% vs 3.0%). With respect to cell research, while fewer articles reported the sex of the cell studied (11.4% vs. 24.0%), if sex was included, more articles included both sexes (60.0% vs 7.0%). Overall sex matching continued to remain poor with only 50.2% human, 4.2% animal, and 11.4% cell studies matching the inclusion of both sexes by 50%. Conclusion: Sex bias persists in all forms of surgical research. Although there are a few notable improvements with more animal and cell research articles studying both sexes, significant disparities remain.Abstract ID: 89Is the Small Bowel a Safe Haven for Melanoma Metastases During Nivolumab Treatment?Introduction: Cutaneous melanoma is a malignancy that can metastasize to the small bowel. In the past year we identified two patients with symptomatic small bowel melanoma metastases that had been rendered surgically NED (no evidence of disease) and had received immunotherapy with Nivolumab. Intriguingly, immune mediated small bowel enteritis is a known side effect of this immunotherapy. The authors hypothesize the small bowel, an organ with great immunologic physiology, provides a safe haven for metastatic melanoma during immunotherapy. Case Series: This cases series involves two male patients receiving adjuvant immunotherapy with Nivolumab having previously been NED. Both patients required bowel resection. The first patient, a 41 year-old male, was diagnosed with cutaneous melanoma in October 2018, the patient underwent wide local excision and sentinel lymph node biopsy and was started on Nivolumab in December 2018. In September 2019, while on immunotherapy, the patient developed intussusception with a small bowel obstruction secondary to a large melanoma metastasis. The second patient, an 83 year-old male, diagnosed with melanoma in May 2016 received Nivolumab until 2018. The patient was clinically stable but noted to have small bowel thickening on surveillance imaging and Nivolumab was restarted in April 2019. After 7 additional months of immunotherapy, the patient developed syncope and was found to be anemic. A small bowel resection of the mass was performed for a large metastatic melanoma. Discussion: Nivolumab as monotherapy for advanced melanoma has been shown to prolong progression-free survival and overall survival. However, this small case series demonstrates the development of small bowel metastases in otherwise stable patients on immunotherapy. These finding suggest that small bowel may not respond as favorably as other potential metastatic sites for melanoma.Abstract ID: 90Doctor’s Orders: An Analysis of Patient Refusal of Pharmacologic Venous Thromboembolism ProphylaxisIntroduction: Venous thromboembolism (VTE) occurs between 10-40% of patients during or after hospitalizations. Pharmacologic VTE prophylaxis is refused almost twice as often by inpatients than any other medication. We sought to define factors influencing noncompliance with VTE prophylaxis, exploring relative contributions of nursing unit culture, clinical service type, and medication characteristics on patient refusal of VTE prophylaxis at a single institution.Methods: Retrospective review of inpatients at a quaternary, urban academic medical center over a five-year period who were prescribed a pharmacologic agent for VTE prophylaxis. Variables reviewed included medication type, administration timing, hospital unit, and admitting service. Refusal rates were compared across groups using a parametric ANOVA with a Duncan multiple comparison deflator. A forward selection logistic regression model was performed to determine relative contribution of each variable after adjustment for other variables. Results: >180,000 doses of pharmacologic VTE prophylaxis for 192,704 patients were analyzed. Enoxaparin was most commonly prescribed. The pharmacologic agent was associated with significantly different rates of refusal: heparin 8.4%, enoxaparin 4.7%, and fondaparinux 2.6% (p<0.05 for all). Dose timing was also associated with a small but significant differential refusal rate: 12 AM- 8AM 6.9%, 8AM-4PM 6.2%, and 4PM- 12 AM 6.0% (p<0.05). Units with primarily medicine patients had significantly higher rates of refusal (9.9%) compared to surgery (2.6%) or ICU units (2.6%) (p<0.05). Surgical patients on surgical units had the lowest rate of refusal (2.3%) compared to medical patients on medical units (10%) (p<0.05).Conclusion: Multiple factors are associated with refusal of pharmacologic VTE prophylaxis. Enoxaparin or fondaparinux is less likely to be refused than unfractionated heparin raising questions about injection burden on refusals. Prescribing a once daily dose in the afternoon may increase adherence. Surgical services and units had lower rates of patient refusal which may be due to differences in clinical microsystem culture.Abstract ID: 91Prior Antimicrobial Exposure is Associated with Reoperation After Elective Non-Colorectal SurgeryIntroduction: In a limited single-center study, antimicrobial exposure 90 days prior to elective non-colorectal surgery has been linked to higher rates of complications, infections, and lengths of stay. This study examines the effects of recent antimicrobial exposure prior to elective non-colorectal surgery across a national sample. In this multicenter cohort of colorectal surgery patients, we hypothesized that recent antimicrobial exposure would be associated with poor outcomes.Methods: Using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and outpatient VA pharmacy data, we included adult patients undergoing elective non-colorectal surgery from 2013–2017, who were exposed to antimicrobials within 90 days prior to surgery. Exclusion criteria consisted of immunosuppression within 1 year of surgery, inpatient admissions within 90 days of surgery, intra-operative dirty/infected wounds, and/or intra-operative SIRS, sepsis, or septic shock. Primary outcomes included VASQIP-defined complication rates, infection rates, and rates of unplanned return to the operating room. Standard univariate statistics were used. Multiple logistic regression was used performed. The threshold for significance was p<0.01.Results: 21,112 patients met eligibility, 2,885 (13.7%) were exposed to outpatient antimicrobials prior to surgery. Exposed patients were more likely to be female (26.9% vs. 36.0%) or have COPD (9.7% vs. 11.8%), but were less likely to have a clean (46.6% vs. 20.5%) or clean-contaminated (32.2% vs. 21.0%) wound classification. Exposed patients had higher rates of complication (7.1% vs 8.5%), longer length of stay, and higher rates of unplanned return to the operating room (2.7% vs 3.8%). On multivariable analysis, recent antimicrobial exposure was independently associated with unplanned return to the operating room (OR: 1.39; 99% CI: 1.05-1.84) only.Conclusion: After recent antimicrobial exposure in an elective non-colorectal surgery cohort, there was an elevated rate of return to the operating room. Pre-operative dysbiosis due to antimicrobial exposure is a possibility, although post-operative infection risks were not different. More work is needed to further characterize this association.Abstract ID: 92Identifying Patients at Risk of Delayed Recovery After Elective SurgeryIntroduction: Wearable devices have potential to quantify both preoperative and postoperative activity. Our prior work has characterized postoperative recovery trajectories, measured by steps-per-day compared to baseline. This study aims to identify risk factors for delayed recovery to baseline at one month post-surgery.Methods: Patients were prospectively enrolled prior to elective inpatient abdominal surgery. An activity monitor was worn for at least 3 days preoperatively and 28 days postoperatively. Steps-per-day on each postoperative day (POD) were compared to preoperative baseline steps. Achieving at least 50% of baseline steps on POD 26-28 was considered normal recovery. Multiple preoperative, intraoperative, and postoperative factors were examined to determine if they were predictive of delayed recovery.Results: 108 patients were included; 93% were male and median age was 66 years. Overall, 45% underwent open and 55% underwent minimally-invasive procedures. At one month postoperatively, 32 (30%) of patients had delayed recovery. These patients did not differ from normal recovery patients in terms of age, gender, frailty, or steps-per-day at baseline. However, Charlson Comorbidity Index was higher in delayed recovery patients (3 vs. 2, p=0.04) and these patients were more likely to have experienced multiple falls in the past 6 months (13% vs. 1%, p=0.04). Longer operative time, higher blood loss, and open approach were highly predictive of delayed recovery. Finally, after POD 1, percent recovery differed significantly between the two groups, suggesting that patients who will ultimately have delayed recovery can be identified early in their postoperative course.Conclusions: Most preoperative variables were not predictive of delayed recovery; recovery seems driven by intraoperative variables and type of procedure. Patients with delayed recovery, if they continue to recover at the same rate, will not be fully recovered for 3-4 months. These patients can be identified in the early postoperative period, allowing supportive intervention to improve recovery time.Abstract ID: 93Oncological resection for gallbladder cancer in the US: quality of lymph node dissection and its impact on survivalIntroduction: Gallbladder cancer remains associated with extremely poor overall survival. Surgery is the only therapy that offers the best chance for cure and improved survival. However, there is a paucity of data on the quality of the oncological resection of gallbladder cancer. Herein, we aim to assess the rate of lymph node examination during radical cholecystectomy and its impact on survival. Methods: A 16-year analysis of the Surveillance, Epidemiology, and End Results Program (SEER) database was conducted. All adult patients who underwent oncological resection for gallbladder adenocarcinoma were included in the analysis. Patients were stratified into two groups based on lymph node examination: Node examination (NE) vs. No Node Examination (NNE). The outcome measures were factors associated with the lack of lymph node examination and long-term survival. Multivariate regression and survival analyses were performed. Results: A total of 6,552 patients were included in the analysis, of which 43% (n=2,855) underwent lymph node examination during resection. The mean age was 70.1 (±12.10), 28.6% were males, 90% had ≥ stage II adenocarcinoma, 33% received chemotherapy alone, 26.4% chemoradiotherapy (CRT). Patients in the NNE group were more likely to be older (71.72±11.66 Vs. 67.62±12.20, p<0.01, to have more advanced tumors ≥ stage II (28% vs. 27%, p<0.01), and to be less likely to receive chemotherapy or radiation therapy (72.9% vs. 55.5%, p<0.01). On multivariate analysis, older patients had higher odds of not having lymph nodes examined (OR: 1.02 [1.01-1.02], p<0.01). NNE is associated with lower odds of receiving chemotherapy or CRT (aOR 0.784 [0.677, 0.907] p<0.01 and aOR: 0.37 [0.31-0.43] p<0.01, respectively). No lymph node examination during oncological resection was independently associated with worse overall survival.Conclusion: Less than half of the patients who underwent oncological resection for gallbladder adenocarcinoma had lymph node dissection. Lack of lymph node examination is independently associated with worse overall survival.Abstract ID: 94Racial Disparities Among Frail Cardiac Surgery Patients: The Role of Patient and Hospital Factors at Minority-Serving HospitalsINTRODUCTION:Poor cardiac surgery outcomes among minority populations are often attributed to lower hospital quality. However, a significant fraction of racial disparities remains unexplained. This study aimed to demonstrate the disparity in outcomes of frail patients at minority-serving hospitals (MSH) and the relative contribution of patient and hospital factors.METHODS:Of over 4 million cardiac surgery patients 2000-2014 from the Nationwide Inpatient Sample, 64,753 patients were defined as frail based on the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. 11,185 received care at a MSH. Multivariable regression modeling and propensity-score matching were used to measure the relative contribution of patient and hospital factors and the association between MSH status and outcomes respectively.RESULTS:Patients at MSH were more likely to be frail (2.3% vs 1.5%; p<0.0001), Medicaid beneficiaries, within the lowest income quartile, and undergoing surgery for an urgent indication. MSH were more likely small-volume urban government-owned centers. Unadjusted mortality (11% vs 9%; p=0.01) and complications (84% vs 79%; p<0.0001) including respiratory failure, pulmonary embolism, and sepsis were significantly higher among frail patients at MSH. When adjusted for demographics and comorbidities, complications remained significantly higher at MSH (p=0.007), but mortality did not. Costs at MSH increased by over $12,000 (p=0.0002). Patient factors contributed to 43% of the increase in odds for complications at MSH while hospital and procedure factors contributed about 3% and 51% respectively. Among patients at MSH, odds of complications were higher among African Americans (p=0.02) compared to white patients, but were not increased for other individual minorities.CONCLUSIONS:Cardiac surgery outcomes among frail patients at MSH appear to be worse with higher associated costs. As outcomes in these institutions are largely influenced by patient and procedural factors versus hospital factors, an integrative, multi-disciplinary collaboration with tertiary centers may provide an avenue to improve outcomes and reduce the existing disparities in outcomes. ................
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